Adult Registration Form

    1. Patient Details

    Title (required)

    First Name (required)

    Last Name (required)

    Date of Birth* (required)

    Age (required)

    Gender (required)


    Year Level

    Address (required)

    Suburb (required)

    State (required)

    Post Code(required)

    Work Phone (required)

    Mobile Phone (required)

    Email (required)

    2. 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.




    Provider Numbber:

    GP’s details if different




    Provider Numbber:

    3. 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.

    * 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


    Suite 204, Specialist Centre
    Joondalup Health Campus
    Shenton Avenue
    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
    Tel : 6319 2809
    Fax : 6319 2810

    Opening Hours

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

    Copyright by Allergy Medik. All rights reserved.