Newborn

Newborn Patient Registration Form

We are committed to providing our patients with the best care. To do this, it is essential that your health record contains complete and accurate information. Please assist us by completing our patient registration form.

BIRTH INFORMATION

Paeditrician *

Obstetrician *

Hospital of Birth *

Birth weight *

Delivered at how many weeks? *

YOUR NEWBORN BABY'S DETAILS

First Name *

Last Name *

Date of Birth *

Gender *

Home Address *

City / Suburb *

Postcode *

Is the postal address the same as the home address? *

YesNo

Postal Address *

Postal City / Suburb *

Postal State *

Postal Postcode *

Is your baby eligible to receive Medicare? *

YesYes but not registered yetNo

Medicare Card Number (Patient) *

Ref (Patient) *

Patient Name on Medicare Card

PARENT 1 / GUARDIAN 1

First Name (1) *

Last Name (1) *

Relationship to patient (1) *

DOB (1) *

Is Parent 1 address the same as the baby? *

YesNo

Address (1) *

City / Suburb (1) *

State (1) *

Postcode (1) *

Phone Number (1) *

Email (1) *

Does Parent 1 / Guardian 1 have Medicare? *

YesNo

Medicare Card Number (1) *

Ref (1) *

Name on Medicare Card (1) *

PARENT 2 / GUARDIAN 2

First Name (2)

Last Name (2)

Relationship to patient (2)

DOB (2)

Is Parent 2 address the same as the baby?

YesNo

Address (2)

City / Suburb (2)

State (2)

Postcode (2)

Phone Number (2)

Email (2)

Does Parent 2 / Guardian 2 have Medicare?

YesNo

Medicare Card Number (2) *

Ref (2) *

Name on Medicare Card (2) *

CARE AND LEGAL STATUS

Are the parents/guardians currently separated? *

YesNo

Are there any court orders relating to the care or custodianship of the patient? *

YesNo

Please provide details

Are any third parties (eg DHHS) involved in the care or custodianship of the patient? *

YesNo

Organisation

Contact person

Contact phone number

GP DETAILS FOR CORRESPONDENCE

Name of Family GP

GP Clinic *

Phone number for GP

GP Clinic Address

DOCUMENTS TO ATTACH - GP REFERRAL, PATHOLOGY ETC

Referral to upload

Browse

CONSENT

By signing this form, you acknowledge and consent to the following:

Accuracy of Information.
I confirm that the information I have provided is true, complete, and accurate to the best of my knowledge.
Privacy Policy.
Monash Obstetrics Kids complies with the Victorian Health Records Act 2001 and the Commonwealth Privacy Act 1988. We require your consent to collect, store, and manage personal and health information related to you or your child. By establishing a file for you and your child and attending appointments with our clinicians, you consent to the collection and management of this information in accordance with our Privacy Policy. If you have any questions or concerns, please contact us for further clarification.
Electronic Claims to Medicare.
I authorise Monash Obstetrics Kids to electronically transmit claims for Medicare benefits to Medicare Australia on my behalf. I understand that my child must attend all scheduled appointments to be eligible for the Medicare rebate. Failure to attend appointments will make me ineligible to claim the Medicare rebate for that visit.
Fees for This Practice
I acknowledge and agree to the following:
- I am financially responsible for payment of all fees at the time of the appointment.
- There will be an out-of-pocket expense for each appointment.
- It is my responsibility to ensure that a valid GP referral is provided for each visit to enable Medicare claims.
- I understand that my child must be present at the appointment to be eligible for Medicare rebate.
Methods of Communication.
I understand that Monash Obstetrics Kids may use various methods of communication, including telephone, SMS, email, and postal mail, to manage my care.
Cancellation Policy.
I understand that as there is a waitlist for Paediatrician appointments, early cancellation allows us to offer the time slot to another family. Late cancellations (within 48 hours) or no-shows without prior notice may incur a fee ranging from $50 to $100 for the missed appointment.
Consent Forms and Questionnaires.
I understand that additional consent forms and questionnaires may be required and must be completed and signed by both parents. Appointments or treatments may be delayed until all necessary forms are received.
Mandatory Reporting.
I acknowledge that paediatricians are required by law to notify Child Protection Services if they have significant concerns about my child’s well-being.
Use of AI Scribing Software.
I understand that specialists at Monash Obstetrics Kids may use AI-powered medical scribing software during consultations. This software transcribes conversations into clinical notes and letters, enabling the doctor to focus on providing personalised care. All data is securely stored and accessible only to the doctor, with the highest standards of data security and privacy protection. By signing this form, I consent to the use of AI scribing software. I understand that I can withdraw my consent at any time without affecting my child’s ongoing care.

By signing below, I acknowledge, understand and give consent to the above

*

Parent/Guardian name *

Patient/ Guardian Signature *

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Today's Date *

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