Patient Registration Form

Please complete this form at your earliest convenience

The form may be partially completed, saved, and completed at a later time

Payment for all rooms consultations is on the day, please see our website for fee information. We are able to submit your rebate claim direct to Medicare electronically for you, as long as you have a current referral. 

Patient details


Patient contact details

Consultation fees

Please see our website FAQ and Links tab for details of consultation fees for rooms and hospital visits. In the event where your overdue account is referred to a collection agency and/or law firm, you will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand costs.         Please note that a Medicare subsidy is payable only with a current referral

Medicare number

Private Health Insurance

Pension / HCC/DVA Card or TAC/Workcover

(mm/yyyy)

Reason for referral

Referring doctor to us

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Health information

Nutrition information

Lifestyle - do you:


Allergies

Health history - please tick if "Yes", and provide further info for all answered as "Yes"

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Medications

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Final questions

Signature

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