Patient Registration "*" indicates required fields Name* Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title Given name Surname Email* D.O.B Home phone Mobile phone* Address Street Address Suburb Post Code Medicare Number: Ref: Exp: Private Health Insurer: Membership Number: Veteran Affairs Number: Colour: Gold White Aged Pension Card Number: General PractitionerGP Name Dr.Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Clinic name: Address Street Address Suburb Postcode Referring Doctor Dr.Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Referring Doctor Clinic name: Referring Doctor Address Street Address Suburb Postcode Patient detailsPlease indicate any illness or conditions you have had: Heart trouble High Blood pressure Cancer Nervous disorder Asthma Bleeding problems Stroke Diabetes List of scans (Pathology/Radiology) you have done recently (and where):Please list illnesses for which you have been hospitalisedAre you a smoker? No Yes Do you have any allergies? No Yes Are you taking any blood thinners? Asprin Warfarin Other Other blood thinners: Please list your current medications:Fees payable and Privacy Policy Initial consultation: $240.00 Review consultation: $110.00 Workcover, TAC, DVA accounts will be sent direct if correct details are provided. In the event of an account being overdue, it may be referred to a collection agency and/or law firm, you will be liable for all costs which would be incurred as if the debt is collected in full, including commission on collection of the additional costs and also including legal demand costs. Overdue accounts will be subject to interest at the rate of 13% p.a., calculated for the period the account is due until the date it is paid. PRIVACY POLICY: I understand that this practice handles personal information in accordance with the National Privacy Principals enshrined in the Privacy Act 1988 (Commonwealth) and as outlined in the Privacy statement. I consent for the handling of my information by this practice for the purpose of providing quality healthcare, associate administrative billing purposes and other treating allied health professional. I also give permission for my medical information to be obtained from any other source to help with my treatment (Eg. Radiology and Pathology) BERWICK COLORECTAL AND SURGICAL SPECIALISTS DO NOT BULK BILL. For patients that require a BULK BILLING consultation, there is a public outpatient’s clinic at Monash Health. Your GP can arrange an appointment by faxing a referral to the clinic directly. NOTE: You may NOT be seen by one of our surgeons if reviewed in the public outpatient’s clinic. PROCEDURES/DRESSING IN ROOMS Procedures and dressings in rooms may include an additional fee between $60-$250. The facility fee is non-negotiable. Our staff will provide a quote prior to any extra fees being added. PRIVATE (AND SELF FUNDED) PATIENTS HAVING SURGERY IN A PRIVATE HOSPITAL Our surgeons do charge an out-of-pocket fee “gap” for all procedures done in the private hospital. This payment is required prior to surgery. The Anaesthetist and Assistant surgeon may also charge an out of pocket. I HAVE READ AN UNDERSTOOD THE ABOVE "FEES PAYABLE AND PRIVACY POLICY"* Yes No Name* First Last Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY CAPTCHA
