Patient Registration Form

PATIENT REGISTRATION FORM

Please fill out ALL of this form to ensure we can provide the best possible care available

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Personal Information

Residential Address

Postal Address

Please enter your Postal address if diffrent from your Residential addresss

Contact Details

for confidentiality, provide personal email address only

Culture & Language

Medicare Details

Concession Details

Next of Kin & Emergency Contact

Children under 16

Children under 16 need to have an adult as the primary account holder (appearing on the same Medicare card) as Medicare will not accept claims for children.

Please provide your details

Privacy policy

I understand that View Street Medical complies with the Privacy Act (1988) and the Australian Privacy Principles (APP). As part of their Privacy Policy they are committed to protecting the privacy of individuals and their personal information. The purpose of collecting my personal information is to provide quality medical and health related services and associated business processes (eg. financial claims and payments, practice audits and accreditation). I understand that the staff and doctors at View Street Medical make every effort to manage my information in accordance with the Australian Privacy Policy Principles and keep my records accurate and up to date. I understand that I may withdraw my consent for View Street Medical to use and disclose my personal information except when legal obligations must be met. This practice uses a recall and reminder system to enable a systematic approach to health promotion and preventative care. My signature below indicates that I have read the above and consent to the following: • View Street Medical collecting, using and storing of my personal information for the purposes of medical and health related services and associated business processes • The release of relevant personal information to other health professionals to allow quality medical care (eg. medical specialists) • The release of relevant personal information to employer/prospective employer, their authorised representative and their insurer in case of a work-related consultation or service with my informed consent • Inclusion in a recall register to be advised of follow-up visits, medical updates and health information A copy of our Privacy Policy is available on request.

NON-ATTENDANCE FEES

View Street Medical will issue an account fee of $30 in the instance a person fails to attend an appointment on 3 or more occasions without adequate prior notice. By not cancelling the appointment prior it reduces the availability of appointments for other patients.

SMS CONSENT

Please do not attend the practice if you have fever or flu-like symptoms such as sore throat or cough, please inform our reception staff and they will arrange a telehealth appointment for you, with one of our Doctors.
The Doctor may be able to help you with your problem without physically seeing you, including arranging any necessary tests, prescriptions or work certificates – Please be advised that telehealth appointments may incur a private fee.
Should you have a telehealth appointment booked please ensure that your phone is charged and near you.
If the doctor determines you need to be seen in person then an appointment will be arranged for you to attend the practice.

Accept