02 8882 9477
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New Patient Registration
Please complete all relevant fields after calling 02 8882 9477 to
make your appointment
1
Contact Info
2
Medical Accounts
3
GP Info
4
General Info
5
History
Contact Information
Title
Surname
First Name
Address
City
State
Postcode
Home Phone
Work Phone
Mobile Phone
Email
Enter Email
Confirm Email
Date of Birth
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.
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
Parent's Medicare Number
Parent's Ref. Number on Medicare Card
Parent's Medicare Card Expiry
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.
Please upload a copy of the referral letter from your GP.
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.
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
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