Patient Registration Form

Personal Details

First name(Required)

Last name(Required)

Preferred name

Middle name

Sex

Male

Female

Other

Date of birth(Required)

Preferred language

Occupation

Marital status

Contact Details

Address(Required)

Postcode(Required)

Home phone

Mobile(Required)

Work phone

Email(Required)

Next of Kin / Emergency Contact

Name(Required)

Relationship(Required)

Phone(Required)

General Practitioner

GP name(Required)

Phone(Required)

Clinic name(Required)

Clinic suburb(Required)

If your GP above was not the referrer, please provide details of your referring doctor below:

Referrer name

Phone

Clinic name

Clinic suburb

Other Treating Specialists

List

Specialist name

Phone

Clinic name

Clinic suburb

Consultation Fees

Consultation Fees are to be settled at the time of your appointment. Payment can be made by cash or credit/debit card (American Express, Amex and Diners not accepted). For your convenience, we can process the Medicare rebate at the time of consultation. A copy of our fee schedule can be sent to you upon request.

Medicare

Medicare number(Required)

Ref number(Required)

Expiry(Required)

Health fund

Health fund name

Membership number

Health Care card

Health Care card number

Expiry

Pensioner card

Pensioner card number

Expiry

Department of Veterans' Affairs

Veterans' Affairs number

Expiry

Work Cover

Work Cover insurer

Claim number

TAC

TAC claim number

Electronic Communication Policy

At Northern Blood and Cancer Care, we recognise the importance of effective communication with our patients and staff. Our Electronic Communication Policy outlines the appropriate use of electronic communications including SMS and email for communicating sensitive information, ensuring the confidentiality and security of patient data. A detailed version of this Policy can be found on our website, or a copy can be sent to you upon request. If you have any questions regarding this Policy, please contact us on (03) 8408 6000.

1. Purpose of Electronic Communication: Electronic communication may be used for appointment scheduling and reminders, general inquiries and non-urgent communication, sending educational materials and health information, and communication with other practitioners.

2. Security and Confidentiality: All electronic communications including email may contain protected health information (PHI). We will take all reasonable measures to protect the security and confidentiality of information sent and received but this cannot be guaranteed.

3. Patient Responsibility: Patients should ensure that their contact details including mobile phone number and email address are kept up to date, and that their access to these accounts is secure

Privacy Policy

The information collected is used for the primary purpose of providing quality healthcare and may be utilised in the following ways:

1. Administrative purposes connected to running the medical practice

2. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements

3. Disclosure to others involved in your health care, including treating doctors and specialists outside of this practice. This may occur through referral to other doctors or for medical investigations and in the reports or results returned to your doctor following referrals.

Patient Consent

I have been informed of the fee schedule. I understand that I am financially responsible for all medical services provided by Northern Blood and Cancer Care. I agree to pay all charges for services not covered by my insurance, including co-pays and any outstanding balances.

I consent to the use of electronic communication for correspondence. I acknowledge that I understand and agree to the Electronic Communication Policy outlined by Northern Blood and Cancer Care. This includes the understanding that electronic communication may not be a secure method of communication for sensitive information.

I have read and understood the above information regarding my medical information.

Signature(Required)

Date(Required)