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Patient Registration Form

Patient Registration Form

Your Details

Title
Surname
First Name
Middle Name
Address
Date of Birth
Occupation
Phone
Work Phone
Mobile Phone
Email

Next of Kin / Contact Person

Name
Relationship
Contact Number

Medicare

Medicare No,
Reference No.
Expiry Date
Name of Private Health Fund
Membership Number
Cover Type
Extras Cover Only
Hospital Cover Only
Combined Hospital and Extras Cover Only

Medical History

Do you have or have you ever had:
High Blood Pressure
Diabetes
High Cholestrol
Heart Disease
Lung Disease
Stroke / TIA
If Yes, When?
Do you smoke?
No
Yes
Home many per day?
Do you have any allergies to medication prescribed or herbal & or wound dressings?
Any previous operations? If yes, please outline
Have you or any family members ever had any problems or complications from having an anaesthetic

Medications

Medications

Lifestyle

Does your lifestyle/occupation place you in a high-risk group for any of the following? (please select any that may apply)
CJD
HIV
Mad Cow Disease

Information About Fees

Please note that this practice does not bulk bill for consultations by the doctor, you will be required to pay the fee for the consultation before leaving the practice.

All surgical fees for in hospital procedures may not be covered TOTALLY by your health fund. The reception staff upon notification of you requiring a procedure will provide you with a quote of item number to be used showing the gap they may be required to be paid by you.

This Gap payment will be required to be paid prior to any procedure unless otherwise informed.

Please be aware that some health funds do not allow us to bill them directly if a gap on a procedure has been charged. Our staff will advise you if you’re Health Funds is one of these, you will then be responsible for the Total of all fees to be charged for your procedure with these fees being required to be paid prior to your procedure date.

Please note that anaesthetic fees are entirely separate to any billings from NQ Vascular Townsville for procedures. Contact numbers for anaesthetists will be given on all quotes requiring their services and we strongly suggest that you make contact with them and request a quote.

Some procedures will also require imaging to be taken during the procedure please be aware that you may also receive a bill from QLD X-Ray for their services provided which you will be required to pay.

I acknowledge full responsibility for all NQ Vascular Townsville consultation fees including any shortfall in reimbursement by my Health Insurance Fund and Medicare.
I understand the terms above *
Yes

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