Doctor you have appointment with *

First Name * Last Name *

D.O.B *

Email *

Address *

Suburb * State * Post Code *

Gender *

Sex at Birth * Male Female Intersex Prefer not to disclose

Phone Work Mobile *

Occupation

Next of Kin * Contact *

Medicare No. Ref Number

Pension No. War Veterans No.

Private Health Fund Membership No.

Hospital cover Yes No

Have you had hospital cover for more than 12 months? Yes No

If work cover or TAC please provide claim number

Employers Address

Account Holder if patient is under 18 years of age:

Parent name Parent Date of Birth

Relationship Mother Father Legal Guardian

Parent Medicare Reference number

GP Clinic *

Usual General Practioner

Please list any Medical Conditions, Current Medications and Allergies

CONSENT:

Fee Policy:
All consultation fees are to be paid on the day of consultation. Malvern Hill Consulting does not bulk bill consultations. A valid DVA, TAC or other form of approved Work Cover is accepted. The costs for any surgical out of pocket expenses will be discussed with reception following your consultation. Failure to attend a booked appointment, without prior notification, will incur a cancellation fee.

Privacy:

We require you to provide us with your personal details and medical history so that we may properly diagnose, treat and be proactive in managing your health care needs. This practice handles personal information in accordance with the Victorian Health Records Act and the Commonwealth Privacy Act.

I consent to the handling of my information by this practice for the purpose of providing quality health care, associated administrative and billing purposes. I give permission for medical information to be obtained from any other source in order to help with my treatment and to be disclosed to others involved in my health care, including treating doctors and specialists outside this medical practice as advised by you.

I understand that despite all appropriate precautions being taken, protection of my personal information cannot be guaranteed.

I have read the above fee policy and privacy statement, and consent to the taking and use of my medical records as described, and I agree to pay the costs of consultations and any surgical procedures performed.

Online Patient Registration Form

CONSENT: