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.

Both parents are required to read and sign the Consent Form for Families with Separated Parents at the end of this form. The Parent who has received this patient registration form will need to complete Parent 2’s email address. An email will automatically be sent to Parent 2 for them to read and sign.

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.
  

Monash Obstetrics Kids is committed to providing the best possible care for all children. It is in the child’s best interests that both parents collaborate and communicate regarding their health, education, social life, and overall well-being.

Important Notice Regarding Court Orders and Parenting Orders:

We require copies of any court or parenting orders related to decision-making for the child well ahead of the booked appointment date. Failure to provide these documents in advance will result in the booked appointment being postponed or cancelled.

Our paediatricians work with all members of the parenting team to support children effectively. This form outlines essential responsibilities and commitments to help manage your child’s care, minimise conflict, and respect the rights of both parents.

Consent Agreement

Both parents must agree to the following:

• I consent to an assessment and any agreed therapy provided by paediatricians at Monash Obstetrics Kids for my child’s care.

• I agree to maintain a courteous and respectful manner during all consultations.

• I understand that all fees must be paid on the day of the appointment. The parent who books the appointment is responsible for payment and will receive the Medicare rebate (if applicable). Monash Obstetrics Kids will not mediate financial or Medicare claiming disputes between parents.

• I understand that in joint parenting arrangements, the parent booking the appointment must inform the other parent of the appointment time and confirm availability beforehand. Our reminder system only sends SMS notifications to the booking parent.

• I acknowledge that if I wish to see the paediatrician without the other parent, it is my responsibility to make arrangements based on my court order, parenting agreement, or mutual consent. Monash Obstetrics Kids and the paediatrician will not act as intermediaries in such matters.

• I understand that if I wish to see the paediatrician without my child and the other parent, I must book a separate appointment, pay the full fee, and that the consultation will not be eligible for a Medicare rebate.

• I agree that copies of correspondence will be provided to both parents if both are present at the appointment. If only one parent attends, it is their responsibility to share the information with the other parent.

• I acknowledge that the paediatrician may include relevant information provided by either parent in reports.

• I acknowledge that if there is any risk of harm to the child or a mandatory reporting obligation, the paediatrician is legally required to report this to the Department of Families, Fairness, and Housing (DFFH).

• I understand that to ensure the paediatrician has a comprehensive understanding of the child’s behaviour, symptoms, and needs in both homes, both parents must complete any required questionnaires for screening symptoms related to the child. This step is essential for the accurate assessment of the child’s health and well-being.

The paediatricians at Monash Obstetrics Kids reserve the right to decline care, assessments, or services if the above requirements are not met, or if either parent is behaving in a way that may negatively affect the child’s well-being.