test-page

PATIENT REGISTRATION FORM

PARENT/GUARDIAN DETAILS (If patient is under 18 years old)

NAME
ADDRESS
POST CODE	TELEPHONE	DATE OF BIRTH
MEDICARE		REF#
Do you suffer any drug allergy? NoYes		Please specify:

CONSULTATION FEES

Description	Fee	Medicare Rebate	Out of pocket (approx.)
Initial consultation	$220	$72.75	$147.25
Review consultation	$120	$36.55	$83.45
Ear Toilet	$160	$93.45	$66.55
Nasendoscopy	$200	$104.45	$95.55
Nasal cauterisation	$140	$76.50	$63.50
Oximetry	$150	$117.90	$32.10
Replacement Prescription Fee	$5

Please note, we only accept EFTPOS payments.

*Prices correct as of 1st July 2017 and subject to change without previous notice.

**After 1st of July 2014 this medical practice no longer offers concession card discounts, pensioner card discounts or bulk billing.

By ticking this box 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.

[recaptcha]

TITLE: MRMRSMSMISSMASTER	SURNAME
GIVEN NAMES	DATE OF BIRTH
TELEPHONE (HOME)	(MOBILE) (WORK)
EMAIL ADDRESS
ADDRESS	POST CODE
MEDICARE	REF#
VETERAN’S AFFAIRS (IF APPLICABLE)	GOLDWHITEBLUE
DO YOU HAVE PRIVATE HEALTH INSURANCE NoYes
NAME OF FUND	MEMBERSHIP No.
NEXT OF KIN	TELEPHONE