Patient Registration Form

PATIENT DETAILS

First Name

Last Name

Preferred Name

Date of Birth

How [do/does] [you/Person’s name/they] describe [your/their] gender?

Other term

English is a Second Language

YesNo

ATSI

AboriginalTorres Strait IslanderNone of the Above

PATIENT CONTACT DETAILS

Home Phone

Mobile Phone

Work Phone

Email

Address

Postcode

City / Suburb

State

EMERGENCY CONTACT DETAILS

Name

Home Phone

Mobile Phone

Work Phone

NEXT OF KIN CONTACT DETAILS

Is the next of Kin same as your emergency (if yes, you do not need to fill this section)

YesNo

Next of Kin - Name

Next of kin Home Phone

Next of kin - Mobile Phone

Best way to contact your next of Kin

Home PhoneMobile PhoneWork Phone

REFERRING DOCTOR TO US

Referring Doctor’s Name

Clinic

Regular General Practitioner Name (if different to referring doctor)

Clinic

MEDICARE

Do you use a different name in your medicare card?

YesNo

Please enter your name as it appears on your Medicare Card

Medicare First Name

Medicare Surname

Medicare Card No.

Reference Number (Number next to your name)

Expiry Date

Medicare Address (if different to your residential address)

PRIVATE HEALTH INSURANCE

Do you have private Medical insurance

YesNo

Provider

Membership No.

Expiry

PENSION / HCC/DVA Card

Do you have an aged pension card, healthcare card or a DVA card

YesNo

Card Type

HCCPension

Card No.

Expiry(mm/yyyy)

DVA No.

MY HEALTH RECORD

Uploading of Records to My Health Record

I consent for correspondence being sent to My Health RecordDo not send records to My Health Record

CONSENT

Synergy Cardiology collects information for the primary purpose of providing quality health care. *

I understand that Synergy Cardiology is a private billing practice (not a bulk-billing practice) and that I will need to pay a consult fee or testing fee on the day (Medicare rebate available if eligible)I consent for my information to be collected and stored by Synergy CardiologyI consent for correspondence being sent to third parties (GP, etc)I consent to be contacted by SMS, email and phone

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

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