Child Registration Form





1. Patient Details

Title (required)

First Name (required)

Last Name (required)

Date of Birth* (required)

Age (required)

Gender (required)

School

Year Level

Address (required)

Suburb (required)

State (required)

Post Code(required)

Work Phone (required)

Mobile Phone (required)

2. Parent/Guardian Details

Parent 1

First Name (required)

Last Name (required)

Date of Birth* (required)

Occupation (required)

Email (required)

Phone (required)

Parent 2

First Name

Last Name

Date of Birth*

Occupation

Email

Phone

Account Holder (if not parent)

First Name

Last Name

Date of Birth*

Occupation

Email

Phone

3. Medicare Details

Card Number (required)

Medicare Expiry Date (required)

Patient Position

 

Parent Position

Do you have private health insurance?

if Yes, name of fund and membership number.

Referring Dr.

Name:

Address:

Phone:

Provider Numbber:

GP’s details if different

Name:

Address:

Phone:

Provider Numbber:

4. Privacy Information and Consent

Please carefully read the following information about privacy issues and fees structure, then sign this form where indicated below. Privacy issues I understand that Allergy Medik and the doctors and staff within the group comply with the Privacy Act 1988 and as part of their Privacy Policy they are committed to protecting the Privacy of individuals and their personal information. The main reason why information is collected by this practice is so that we can assess, diagnose and treat your illness and be proactive in your health care needs. This means that we will use the information you provide in the following ways:
1.Administrative purposes in running the medical practice
2.Billing purposes, including compliance with Medicare and Health Insurance Commission requirements,
3.Disclosure to others involved in your healthcare, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in reports or results returned to us following the referrals.

Patient/guardian’s acknowledgement
1. I have read this form and understand why collecting information about me is necessary. I am also aware that this practice has a privacy policy on handling patient information.
2. I understand that I am not obliged to provide any information requested of me. I also understand that failure to provide this medical practice with all the information it needs may restrict the practice’s ability to provide the quality of health care and treatment that I want.
3. I am aware that I have the 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.
4. I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.
5. 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 about which I notify this practice now or at any future time.
6. I acknowledge that I have read this form before signing it and that a member of the staff of this practice has at my request clarified any aspects of it that I did not at first understand.
Fees structure I understand that the cost of a consultation is above the Medicare schedule fee, which means that I will incur an out-of-pocket expense. I have been informed of the fee structure and agree to pay this account at the time of consultation.

* DOB is collected for the purpose of Medicare Online claiming

I have read and understand the above privacy conditions. Yes

Please type your name as consent:

Submission Date

Joondalup

Suite 204, Specialist Centre
Joondalup Health Campus
Shenton Avenue
Joondalup
Western Australia
Tel: 08 9400 9911
Fax: 08 9400 9909

Opening Hours

Monday 9am -5.30pm
Tuesday Closed
Wednesday 9am -5.30pm
Thursday Closed
Friday 9am - 1pm
Saturday Closed
Sunday Closed

My Specialist Rooms

U3/ 24 Parry Ave
Bateman 6150
Western Australia
www.myspecialistrooms.com.au
Tel : 6319 2809
Fax : 6319 2810

Opening Hours

Tuesday 9am-3pm
Saturday “Strictly appointment only”

Copyright by Allergy Medik. All rights reserved.