Patient Registration Form

TITLE (Required)

SURNAME (Required)

FIRST NAME (Required)

MIDDLE NAME

PREFERRED NAME

D.O.B (Required)

Address Street 1 (Required)

Address Street 2

Suburb (Required)

State (Required)

Post Code (Required)

HOME PH

WORK PH

MOBILE NO (Required)

MEDICARE NO

Ref NORef...(No. next to your name)

HEALTH INSURANCE

PROVIDER/FUND

MEMBER NO

VETERANS AFFAIRS NO(if applicable)

DVA Card Colour

Please present Aged or Disability Pension Cards to Reception.

EMERGENCY

CONTACT NAME

CONTACT PHONE NO

RELATIONSHIP

USUAL GP

CLINIC NAME/ADDRESS

ALLERGIES Nil Known

ALLERGIES TO

REACTION

If you have more than 4 allergies, please let our reception staff know

Check here if you accept "TERMS & CONDITIONS OF GM UROLOGY".

TERMS & CONDITIONS OF GM UROLOGY:

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
Informed Financial Consents will be provided for all surgical procedures which will incur an out of pocket expense. These require signature and a copy will be retained by GM Urology.
Please note: Our estimate of fees for surgery do not include Health Fund excess, Anaesthetist, Assistant or Pathology fees. Please speak to our office staff for other provider contact details. Assistant fees are usually charged at approximately 1/5th of the surgeon’s fee.
Invoices for surgery will be forwarded to the nominated health fund (with some exceptions) and out of pocket expenses will be directly billed to the patient.
All consultations/procedures in rooms are payable on the day.
In most instances, a deposit will be required prior to surgery.
If you are not covered by health insurance and for some procedures, all surgical fees must be paid in full prior to surgery.
All other invoices are payable within two weeks of date of invoice.
Unpaid invoices will automatically be sent to a third party debt collection agency and administration fees may be added to your account.