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PATIENT REGISTRATION FORM

MRMRSMSMISSMASTER












GOLDWHITEBLUE
NoYes




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







NoYes

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


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.






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