Registration Form

NEW PATIENT REGISTRATION DETAILS FORM

Please complete this two page form and email it back to info@drtimprice.com.au, or bring it with you on the day of your visit if that is possible.

Title:

FullName:

Home Address:

Suburb:

State:

Postcode:

Postal Address (if different from above):

Suburb:

State:

Postcode:

DOB:

Occupation:

Home Ph:

Work Ph:

Mobile:

SMS:

Email:

Medicare #:

Ref on card:

Expiry Date:

If you have private hospital cover and have been with your health fund for longer than 12 months, please provide the details

Health Fund:

Membership Num:

Additional Support:

Expiry:

Referring Dr:

Specialist:

Usual GP (if different from above) :

GP Address:

Are there other medical practitioners you would like correspondence to be sent to apart from your referring doctor and usual GP?:

Emergency Contact:

Relationship to patient:

Home Ph:

Mobile Ph:

Work Cover / TAC (if applicable, please complete) :

Claim #:

Date of injury:

Children Under 18 Please provide an adult/guardian's details for account purposes:

Child Title:

Child Fullname:

Child DOB:

Medicare #:

Ref on card:

Expiry Date:

PLEASE READ CAREFULLY CONSENT TO COLLECT PATIENT INFORMATION:
This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in the followingways:
1. Administrative purposes in running our medical practice.
2. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements. 3. Disclosure to othersinvolved in your health care, including treating doctors and specialists outside this medical practice as advised by you.

• I understand the reasons why my information must be collected.
• I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given tome.
•I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.
•I understand that if my information is to be used for any purpose other than the above, my consent will be sought. •I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.

CONSULTATIONS: Please note, this is a private practice and it does not bulk bill. This excludes Telehealth appointments this service with the bulk billed under the MBS Telehealth provisions.

The cost for an initial appointment with Dr Timothy Price is $210, with a Medicare rebate of $76.80. Please note, additional fees are applicable if you need any of the following, cautery, ear suction or Nasendoscopy.

Any subsequent appointment has a fee of $110, with a Medicare rebate of $38.60. Please note, additional fees are applicable if you need any of the following, cautery, ear suction or Nasendoscopy.

Payment methods include cash, cheque, EFTPOS or credit card.

SURGERY FEES: Please note, any fees for surgery will be discussed with Dr Tim Price during the consultation. Patients will receive a comprehensive quote detailing the out of pocket costs. Fees for surgery are payable in advance.

I acknowledge this is a private clinic and I will billed upon consultation.

Signed Date:

Signature:

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NEW PATIENT REGISTRATION DETAILS FORM