Burpengary East Medical Centre & Skin Cancer Clinic - GP

NEW GP PATIENT REGISTRATION FORM
If registering a child, please provide the parent or guardian's phone number.
If registering a child, please provide the parent or guardian's email address.

Residency

Cultural Background

Medicare - Healthcare - Pension Card Details

Eg. 0123456789
Eg. 1
Eg. 02/20

Next of Kin

Emergency Contact

Medical History

THIS PRACTICE IS A PRIVATE BILLING PRACTICE.

BULK-BILLING IS NOT ROUTINE & you may receive an account for your visit which must be paid on the day of consultation. Payments can be made by eftpos or credit card. However ,patients on a Pension, Concession or Health Care Card may be Bulk Billed at Doctors discretion. We direct bill all Department of Veteran Affairs Gold Card holders. Certain medical examinations - such as medicals, legal reports & commercial drivers licences are not claimable from Medicare. Full Payment is required on the day for Workcover claims that do not currently have a claim number. You are then able to follow this up with your claim agent. If you require any further information regarding costs please ask reception staff.

Freedom of information

All patient files that include personal information, test results etc. are the property of this practice. However , should you choose to visit another Doctor at any time, copies of the appropriate files can be forwarded on receipt of your written request. Under no circumstance will this practice divulge personal information without your prior written consent.

Consent

I have read the information and I consent to have my Skincheck. I understand that skin liaison and Miles can occur over time and I would return to the clinic if any such changes occurred and I would return for follow-up previous as recommended.
The patient must sign to confirm that they agree.