PATIENT REGISTRATION FORM

Title

Name *

First

Last

Date of Birth *

Residential Address *

Postal Address (if different from above)

Email Adress *

Best contact number *

Additional phone numbers

Emergency Contact

Privacy requirements: list persons and contact number who have authority to access your medical/dental/account details.

Medicare Number *

Expiry Date *

Patient ID Number (number in front of your name) *

Private Health Fund. If you are in a health fund, please continue to fill in all your details below. *

Name of Health Fund

Policy Holder's Name

Membership Number

Patient ID Number

Have you been in this health fund for longer than 12 months?

Level of Cover

Department of Veteran's Card Number (if applicable)

Are your bank details registered with Medicare?

No
Yes

Do you give financial consent for your treatment? Please read the description below before giving your choice. *

Personal cheques are not accepted. Payment of consultation is required on date of service. I understand there is a prepayment for further medical treatment and is payable two weeks in advance of procedures. A final itemised account will be issued upon completion of any procedure. Accounts fall due immediately on completion of procedure. If it is not finalised promptly, the debt will be passed on for collection. The patient will be liable for all expenses, costs and/or disbursements incurred in recovering any overdue monies, including debt collection fees, solicitor's fees and legal costs on a full indemnity basis. I consent to verification of Medicare card details. For no gap claims and Medicare bulk billing, I assign my benefit right to the Practitioner who rendered the service.

Family Doctor (GP) and suburb

Family Dentist and suburb

Do you have any allergies? *

Please list any allergies below:

Please tick any medical conditions which you have been diagnosed with:

Do you smoke?

No
Yes

Please list any medications or natural supplements you take:

Please write any further information regarding your medical history that you feel is relevant:

DR ANTHONY ROBERT BERTRAM

Menai

WESTMEAD