Welcome to our practice

Please read and carefully fill out the details below.

Payment is required on the day of your consultation. We can process Medicare claims online at our rooms. If you would like us to send off your claim, please fill in your details below including bank details, BSB and account number which we can then store in your file. You will then receive your refund direct to your account within 24 to 48 hours.

 

Title Surname First Name Date of Birth Residential Address Religion Telephone Home Telephone Work Telephone Mobile Email Occupation Medicare Number Individual Reference Number Expiry Date BSB Account Number Account Holders Name

Partner's Name Partner's Date of Birth Partner's Occupation Partner's Medicare Details - Fertility patients only Partner's Medicare Number Partner's Reference Number Expiry Date

HEALTH INSURANCE

Are you covered by Private Health Insurance? Name of Health Fund Membership Number

Referring Doctor Regular Doctor (GP)

If we are unable to contact you, please nominate the details of someone whom you wish us to phone.

Next of Kin Name Telephone