New Patient Registration Please complete all relevant fields after calling 02 8882 9477 to make your appointment. Contact Our Team 1Contact Info2Medical Accounts3GP Info4General Info5History Patient InformationTitle* Surname* First Name* Address* City* State* Postcode* Mobile Phone* Home Phone Work Phone Email* Enter Email Confirm Email Date of Birth* DD slash MM slash YYYY Occupation* Emergency Contact Name, Phone Number, Relationship* e.g. John Smith, 02 9999 9999, HusbandImportant informationSydney Hills ENT may, on occasion, wish to communicate with you by email. All email communications are performed with particular regard to the privacy and confidentiality of your health information, however email communication are NOT ENCRYPTED, and therefore carry a higher risk. Email does not replace other forms of communication with your practitioner, such as consultation visits. Consenting to communicate with us by email assumes the following: - You acknowledge that the privacy and confidentiality of your health information may be compromised when communicating by email without encryption. - Only non urgent matters shall be communicated by email, as practice staff may not read all their emails on a daily basis. Urgent matters will always be communicated by telephone.If you hare happy to receive email communications from us you will need to provide your written consent below:* I CONSENT to email communication with and from Sydney Hills ENT. I DO NOT CONSENT to email communication with or from Sydney Hills ENT. If you hare happy to receive SMS communications from us you will need to provide your written consent below:* I do consent to SMS reminders regarding appointments I do not consent to SMS reminders regarding appointments Medical AccountsMedicare Number* Ref. Number on Card* Expiry* Do you have a private health fund Yes No Health Fund* Member Number* When did you join this fund? Within the past 12 months At least 12 months ago DVA File No. (if applicable) Gold/White Is the patient over the age of 18 years? Yes No Parent/Guardian NameAs patient is a child, we require some information of the Parent/Guardian. Title Surname First Name Are there any Parenting Orders that Hills ENT Clinic should be aware of Yes No Please detail any applicable parenting orders:Medicare RebateIf you would like for Hills ENT Clinic to process your child's Medicare Rebate on your behalf please provide the following details:Parent's Date of Birth DD slash MM slash YYYY Parent's Medicare Number Parent's Ref. Number on Medicare Card Parent's Medicare Card Expiry GP's DetailsGP's Name* GP's Address* Referral letter Drop files here or Select files Accepted file types: jpg, pdf, gif, png, doc, docx, tiff, Max. file size: 10 MB, Max. files: 2. Please upload a copy of the referral letter from your GP. General InfoHow did you hear about us GP Specialist Word of mouth Internet Please confirm you agree to the below before proceeding* Sydney Hills ENT is a private medical practice and fees are payable at the time of consultation. The fees charged are based on those recommended by the Australian Medical Association, these will be more than the Medicare rebate. Sydney Hills ENT is not a bulk-billing medical practice. Moreover, there is a higher fee for patients unable to provide a valid referral at the time of consultation. Sydney Hills ENT collects information from you for the primary purpose of providing quality healthcare. Your information is collected and held in accordance with NSW privacy legislation under which you have rights of access and correction. We require you to provide us with your personal details and a full medical history so that we may properly assist, diagnose and treat your medical condition. We will also use the information you provide us with in the following ways: - Administrative purposes in running our medical practice - Billing purposes, including compliance with Medicare and Health Insurance requirements - Disclosure to other General Practitioners and Specialists outside of this practice involved in your health care - Disclosure to other doctors within this practice- The Sydney Hills ENT surgeons may use your de-identified surgical information and outcomes in audit analysis, and/or for teaching or research purposes. I have read and understood the above information and the reasons why my information must be collected. I understand that I am not obliged to provide any information requested of me, but that my failure to do so may compromise the quality of healthcare and treatment given to me. I am aware of my right to access the information collected about me, except in circumstances where access might be legitimately withheld. I understand I will be given an explanation in these circumstances. For legal reasons, your request must be made in writing, and approved by your treating practitioner. Sydney Hills ENT is a private medical practice and fees are payable at the time of consultation. The fees charged are based on those recommended by the Australian Medical Association, these will be more than the Medicare rebate. Sydney Hills ENT collects information from you for the primary purpose of providing quality healthcare. Your information is collected and held in accordance with NSW privacy legislation under which you have rights of access and correction. We require you to provide us with your personal details and a full medical history so that we may properly assist, diagnose and treat your medical condition. We will also use the information you provide us with in the following ways: - Administrative purposes in running our medical practice - Billing purposes, including compliance with Medicare and Health Insurance requirements - Disclosure to other General Practitioners and Specialists outside of this practice involved in your health care - Disclosure to other doctors within this practice I have read and understood the above information and the reasons why my information must be collected. I understand that I am not obliged to provide any information requested of me, but that my failure to do so may compromise the quality of healthcare and treatment given to me. I am aware of my right to access the information collected about me, except in circumstances where access might be legitimately withheld. I understand I will be given an explanation in these circumstances. For legal reasons, your request must be made in writing, and approved by your treating practitioner.Do you currently have or have you ever suffered from any of the following problems? Alcohol Angina / Heart Attack Asthma / Lung Disease Bleeding / Blood disorder Cancer Diabetes Type 1 Diabetes Type 2 Epilepsy Hepatitis / Liver Disease / HIV High Blood Pressure Mental Health Issues Pacemaker / Implants / Stents Smoker Stroke / Clots Stroke / Irregular Heart Beat Thyroid Disorder Other Please detail your mental health issue(s): Other problems: Have you had any previous operations?Procedure Approximate time since the procedure? 0 - 3 months 3 - 6 months 6 - 12 months Greater than 12 months Procedure Approximate time since the procedure? 0 - 3 months 3 - 6 months 6 - 12 months Greater than 12 months Procedure Approximate time since the procedure? 0 - 3 months 3 - 6 months 6 - 12 months Greater than 12 months Procedure Approximate time since the procedure? 0 - 3 months 3 - 6 months 6 - 12 months Greater than 12 months What medications are you currently taking?Medication Dosage Frequency Medication Dosage Frequency Medication Dosage Frequency Medication Dosage Frequency Do you have any known allergies?Allergy / Medication Reaction Allergy / Medication Reaction Allergy / Medication Reaction Allergy / Medication Reaction Δ