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.

PATIENT DETAILS

First Name *

Last Name *

Preferred Name *

Date of Birth *

Gender *

School *

Year level *

Home Address *

City / Suburb *

State *

Postcode *

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

YesNo

Postal Address *

Postal City / Suburb *

Postal State *

Postal Postcode *

Medicare Card Number (Patient)

Ref (Patient)

Patient Name on Medicare Card

Indigenous status *

AboriginalTorres Strait IslanderNeither

PARENT 1 / GUARDIAN 1

First Name (1) *

Last Name (1) *

Relationship to patient (1) *

DOB (1) *

Address (1) *

City / Suburb (1) *

State (1) *

Postcode (1) *

Phone Number (1) *

Email (1) *

Occupation (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)

Address (2)

City / Suburb (2)

State (2)

Postcode (2)

Phone Number (2)

Email (2)

Occupation (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 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

BIRTH AND DEVELOPMENT HISTORY (if known)

Born at which hospital (or other location)?

Birth weight

Delivered at how many weeks?

Immunisation up to date? *

YesNo

How old was your child when she/he ....

Sat up

Crawled

Walked

Spoke first word

Child's medical history

Current Medications

Current concerns. Please outline your current concerns

DOCUMENTS TO ATTACH - GP REFERRAL, PATHOLOGY ETC

Referral to upload

Browse

CONSENT

I confirm that the above information I have provided is true, complete and accurate.
Privacy Policy: Monash Obstetrics Kids is subject to the Victorian Health Records Act 2001 and the Commonwealth Privacy Act 1988. We require your consent to handle any personal and health information about you or your child. By proceeding with the establishment of a file for you of your child, and meeting with our clinicians, you have indicated your consent, and that any personal and health information provided, obtained and recorded by Monash Obstetrics Kids will be kept and managed in accordance with our Privacy Policy. If you have any concerns or questions, please do not hesitate to contact us for further explanation.
Electronic Claims to Medicare: I authorise this practice to electronically transmit claims for Medicare benefits to Medicare Australia on my behalf.
Methods of Communication: I understand that Monash Obstetrics Kids uses the following methods of communication to manage my care: telephone, SMS, email and post.
Fees for this Practice: I understand that
- I am financially responsible for the payment of all fees at the time of the appointment.
- There will be an out-of pocket expense for all appointments
- It is my responsibility to make sure that there is a valid GP referral for each visit, as the Medicare rebate can only be claimed if there is a vaild referral.
- My child must attend all appointments.
Cancellation Policy: As there is a waitlist to see a Paediatrician, early cancellation will enable us to offer an appointment to another child/family waiting to be seen. Late cancellation within 48 hours, or no-show without prior notice may result in a fee of $50-$100 for the missed appointment.

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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