New Patients | Southeast ENT

PATIENT REGISTRATION FORM

Patient Details

Given Names *

Last Name *

Date of Birth *

Email Address *

Phone (Home) *

Phone (Mobile)

Street Address *

Apartment, suite, etc

City *

State *

Postal code *

Country

Medicare Number

Ref

Medicare Expiry Date

Next of Kin *

Phone *

Do you suffer any drug allergy? *NoYes

Please Specify

Do You Have Private Health Insurance? *NoYes

Name of Fund

Membership No.

Parent/Guardian DetailsIf patient is under 18 years old

Name

Date of Birth

Street Address

Apartment, suite, etc

City

State

Postal code

Country

Medicare Number

Ref

Consultation Fees

Description	Fee	Medicare Rebate	Out of Pocket
Initial consultation	$250	$88.40	$161.60
Review consultation	$160	$44.45	$115.55
Ear Toilet 2^nd Ear	$200 $100	$111.85 $55.92	$88.15 $44.08
Nasendoscopy	$250	$124.95	$125.05
Nasal cauterization	$200	$91.60	$108.40
Transtympanic Therapy	$350	$146.55	$203.45
Medical Reports	From $200 (fee may vary dependant upon complexity)
Replacement Prescription Fee	$5.00	N/A	N/A

* Prices correct as of April 2020 and are subject to change without previous notice.

A 1% surcharge applies to all tap, credit/debit card payments.

Southeast ENT Clinicians use AI transcription software to accurately record a transcript of your consultation enabling them to produce more accurate notes for the patient, carers and referring Doctors. No recordings are kept, and all transcriptions/letters are generated in accordance with Southeast ENT’S privacy policy. If you have any queries or concerns, please bring it to the attention of the administration staff.

Please tick the relevant box below and sign to indicate your consent for AI note and letter writing, *I consent to the use of AI typing technology as described aboveI do not consent and understand I may need to seek care elsewhere

Acknowledgements *I acknowledge the clinic's feesI have read and agree to the Privacy Policy

Name (Or Responsible Guardian) *

Date *

Signature of Patient (Or Responsible Guardian) *

By signing this document you acknowledge our Consulting fees and agree with our Privacy Policy. Should you have any enquiry please contact the front desk staff before signing this document. Please note, we only accept EFTPOS payments.