Patient Registration Form

Your Title
First Name *
Address Street
Email *
Date of Birth
Home Phone
Mobile Phone
Partner's Name
Emergency Contact
Yes   No (I give permission for my partner/husband to be given notification of results)
Medicare Number
Ref Number
Private Health Insurance
Yes   No
Hospital Cover
Yes   No
Hospital Cover > 12 Months
Yes   No
Health Fund Name
Membership Number
Usual GP
(Name & Address)
** I have read and understood the fees provided to me at the time of consultation *
Please Tick
** I have been given a copy of the fees for my own records and understand and accept the fee’s charged. *
Please tick
** I have read the Privacy Policy and Consent (see below) and accept this policy *
Please tick
Have you been overseas in the last 14 days, or had close contact with someone who has tested positive for COVID-19 *
Yes    No
Do you have fever, dry cough, shortness of breath, or flu like symptoms *
Yes    No
Have you been tested for COVID-19 *
Yes    No
Are you happy to receive results & other correspondence via email? *
Yes    No
Verification Code:
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* = Required Fields

PAYMENT TERMS: Full Payment of the account is required on the day of consult and in accordance with our fee’s provided to you. If a patient is in default of payment an overdue account will be referred to a debt collection agency, and/or law firm for collection. The patient shall be liable for the recovery costs including agency commissions or legal costs incurred in relation to the debt.

Waverley Womens Health Privacy Policy and Consent

We are committed to protecting the privacy of patient information and to handling your personal information in a responsible manner in accordance with the Privacy Act 1988 therefore we require consent to collect personal information about you.

Please read our policy: (Full policy may be requested by patient)

This Privacy Policy is current from 1st June 2019.

Collection: We collect information that is necessary and relevant to provide you with medical care and treatment, to manage our medical practice. This information may include your name, address, date of birth, gender, health information, family history, credit card and direct debit details and contact details. We collect information in various ways, ie; over the phone, or in writing, in person in our consulting rooms at 2 Stableford Avenue, Glen Waverley or over the internet if you contact with us online. This information may be collected by medical and non-medical staff. We may be required by law to retain medical records for certain periods of time depending on your age at the time we provide services.

Use and Disclosure: We will treat your personal information as strictly private and confidential. We will only use or disclose it for purposes directly related to your care and treatment, or in ways that you would reasonably expect that we may use it for your ongoing care and treatment. We will use the information you provide in the following ways:

  • Administrative purposes in running our medical practice including our Medical Indemnity Provider
  • Billing purposes, including providing information to Medicare and Health Insurers and other organisations responsible for the financial aspects of your care. Disclosure to others involved in your health care, including treating doctors, medical registers, specialist, other doctors in the practice, medical students, radiologists, pathologists, hospitals, and other health care providers and Myhealth record system

I have read the above information and understand the reasons why my information must be collected. I am also aware this practice has a privacy policy for handling patient information (which is available on request)

I am aware I am entitled to request access to your medical records, except in some circumstances where access might legitimately be withheld. An explanation for this will be provided.

I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me

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.

I consent to the handling of my information by this practice for the purpose set out above.