Illawarra ENT - Patient Details & Authority Form

Patient Details

Title *

Given Name (As on Medicare Card) *

Middle Name

Surname *

Known As

Address *

Street address *

City *

State *

Postcode *

Date of Birth *

Gender *

Home Phone

Mobile Phone *

Email Address

Are You in a Private Health Fund for Hospital Cover *

YesNo

Private Health Fund Name

Private Health Fund Number

Have You Been in the Above Health Fund for More Then 12 Months

YesNo

If No, Date Joined

Is English Your First Language *

YesNo

If No, Do You Require an Interpreter

YesNo

Which Language do You Speak

Who is Your Usual GP and Usual Practice *

Do You Have Any Other Doctors or Specialists You Wish to Add to Your Correspondance List *

YesNo

Additional Doctor or Specialist Name and Location 1

Additional Doctor or Specialist Name and Location 2

Additional Doctor or Specialist Name and Location 3

Do You Have Any Allergies *

YesNo

Allergy

Reaction

Allergy

Reaction

Allergy

Reaction

Next of Kin/Alternate Contact Details (For all Patients)

Person Appointed *

Relationship to Patient *

Title *

First Name *

Surname *

Best Contact Phone Number *

Workers Compensation Claim Details (Only if Applicable)

Employer

Occupation

Injury

Date of Injury

Location of Injury

How Did the Injury Occur

Insurance Company

Date of Claim

Claim Number

Case Manager

As a patient (or legal guardian of the patient) of Illawarra ENT, Head & Neck Clinic,
I agree to the following:

Release of any previous medical reports and results to the Doctor’s at the above mentioned clinic.
Collection, use and disclosure of clinical photographs.
Disclosure to other health care professionals, including treating doctors, specialists and allied health providers outside of our practice. This may occur through referrals to other health professionals or pathology/radiology etc and in the reports or results returned to us following referrals.
Disclosure to other doctors in the practice, locums etc attached to the practice for the purpose of patient care and teaching or for research and quality assurance activities to improve individual and community health care and practice management.
I am aware that the maximum fee charged for a standard consultation is $350.00.
I am aware that the maximum fee charge for an extended (long) consultation is $470.00.
If you hold a Pension or Health Care Card from Centrelink the maximum fee is $250.00.
Correspondence will only be directed to referral practitioner and relevant clinicians.
I understand it is my responsibility to follow the recommended plan of tests and management. It is my responsibility to make sure these are booked and followed through.

PLEASE NOTE:

We require 24 hours notice of inability to attend an appointment.
If we do not receive 24 hours notice a non-attendance/late cancelation fee may be charged at a rate of 50% of the expected consultation fee.

Full Name (Of Person Signing) *

Date *

Siganture *

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