Patient Registration - Southern Plastic SurgerySouthern Plastic Surgery

Your Details

Title*

Surname*

First Name*

Other Names

Date Of Birth*

If you are filling this out for your child:

Parent Name

If patient is a child. If Guardian, please indicate your relationship to parent.

Parent Medicare Number

Parent Medicare Reference Number

Parent Date Of Birth

Address*

Street Address City

Home Phone

Work

Mob

Email*

Do you consent to receive SMS messages*

Yes
No

Do you consent to receive Emails*

Yes
No

Do you have a Medicare Card?*

Yes
No

Medicare Number*

Ref Number Beside your name*

Expiry*

Veterans Affairs Number

Do you have Private Health Insurance Hospital Cover?*

Yes
No

Private Health Fund*

Membership Number*

Local Dr.

Clinic Address

Referring Dr.

If different from local doctor.

General Health

Do you have any allergies to medicines/tapes?*

Yes
No

Which medicines/tapes?*

Please list any medications you are taking*

Are you a smoker?*

Yes
No

How many per day?*

Do you have or have had any of the following?

Heart trouble
Psychiatric treatment
Hepatitis
Diabetes
Epilepsy
Stroke
Persistent bleeding
High blood pressure
Are you pregnant?

Please check all that apply.

*

I acknowledge that I have read the privacy policy and accept the payment requirements.

Payments

Please note Professor Coombs DOES NOT bulk bill.

You will receive an account, which should be paid in full with the Secretary following your consultation. We can make the Medicare claim for you if required.

The fees charged by this practice may exceed the Medical Benefit Schedule (MBS) Fee. They will not, in most instances, exceed the Australian Medical association (AMA) FEES.

Privacy Policy

From 21/12/01, the Federal Privacy Act of 1988 has been amended to apply to all doctors in private practice. From 1/7/02 Southern Plastic Surgery will also be covered by the Health Privacy Principles as set out in the Health Records Act (Vic) 2001. The National Privacy Principles (NPPs) and the Health Privacy Principles (HPPs) require that fully informed voluntary consent is obtained before or as soon as practical after the collection of health information. This is particularly important for “secondary purposes” such as auditing surgical results and carrying out clinical research etc. These quality assurance activities should be a normal part of good surgical practice. Record keeping for plastic surgery may be in the form of clinical photographs. The privacy of individual patients is strictly maintained when reporting the results of audits or research to the medical profession. You may request access to your records. A summary of the NPPS and HPPs are available from reception. Please discuss any concerns you have about the privacy of your personal information with Associate Professor Coombs.

By agreeing and submitting the registration form I accept that I have read, and understood the above and consent to patient information and photographs being used for the “secondary purposes” of audit and research by Southern Plastic Surgery.

Telehealth

By submitting this registration form I also consent to consultations by telephone or video consultations where appropriate.

I understand that I will be notified of the associated costs at the time of booking. I also agree to the medicare fee being claimed on my behalf after the consultation.