New Patient Registration

Please complete all relevant fields after calling 02 8882 9477 to make your appointment.

1Contact Info

2Medical Accounts

3GP Info

4General Info

5History

Contact Information
Title
Surname
First Name
Address
City
State
Postcode
Home Phone
Work Phone
Mobile 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, Husband
Important information
Sydney 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.

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Medical Accounts
Medicare 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 Name
As 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 Rebate
If 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

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GP's Details
GP's Name
GP's Address
Referral letter
Drop files here or

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.

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General Info
How 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 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.