NEW FAMILY REGISTRATION & CONSENT FORM

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    PARENT ONE


    First Name (required)

    Middle Name

    Date of Birth (required)

    Address (required)

    Phone Number (required)

    Email (required)

    Do you have a Medicare Card?









     

    PARENT TWO


    First Name (required)

    Middle Name

    Date of Birth (required)

    Occupation

    Do you have a Medicare Card?


     

    EMERGENCY CONTACT PERSON



    CHILD (Please fill out this section if applicable)

    First Name

    Middle Name

    Date of Birth

    Do you have a Medicare Card?

    Reference place on card

     

    MEDICAL HISTORY






















    PREGANCY DETAILS

















    SOCIAL INFORMATION









    IMPORTANT PRACTICE INFORMATION & FINANCIAL CONSENT


    Please note, Flourish Care is a private billing practice. Bulk-billing is NOT routine. You will receive an account for your visit which must be paid on the day of consultation.Payments can be made by cash, eftpos or credit card.

    Consultation Only:

    • Item 36 (20-39mins) $175 (out of pocket $100 after Medicare rebate)
    • Item 44 (40-60mins) $275 (out of pocket $165 after Medicare rebate)

    Premium Care Plan:
    Please contact reception for information

    Mitcham After Birth Visit:
    $200 out of pocket (Please note can not claim back from Medicare or Private Health Insurance)

    PRIVACY
    Amendments to the Privacy Act came into effect in December 2001. As a provider of healthcare services it is important that you are aware of how any personal information collected by this practice is used.
    The personal information collected is that deemed necessary to best attend to, and treat the presenting health condition(s). Personal information is primarily used within the practice, but sometimes it is used to ensure quality and continuity of health care for you and must be partially or fully disclosed to others outside of the organisation, depending on the circumstances. e.g: when referring to a specialist medical practitioner or when requesting blood tests, urine tests, x-rays etc; when itemising accounts for Medicare.

    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.










      PARENT ONE
































       

      PARENT TWO

















       

      EMERGENCY CONTACT PERSON





       

      CHILD (Please fill out this section if applicable)













       

      MEDICAL HISTORY












       

      PREGANCY DETAILS














      SOCIAL INFORMATION






      IMPORTANT PRACTICE INFORMATION & FINANCIAL CONSENT


      Please note, Flourish Care is a private billing practice. Bulk-billing is NOT routine. You will receive an account for your visit which must be paid on the day of consultation.Payments can be made by cash, eftpos or credit card.

      Consultation Only:

      • Item 36 (20-39mins) $175 (out of pocket $100 after Medicare rebate)
      • Item 44 (40-60mins) $275 (out of pocket $165 after Medicare rebate)

      Premium Care Plan:
      Please contact reception for information

      Mitcham After Birth Visit:
      $200 out of pocket (Please note can not claim back from Medicare or Private Health Insurance)

      PRIVACY
      Amendments to the Privacy Act came into effect in December 2001. As a provider of healthcare services it is important that you are aware of how any personal information collected by this practice is used. The personal information collected is that deemed necessary to best attend to, and treat the presenting health condition(s). Personal information is primarily used within the practice, but sometimes it is used to ensure quality and continuity of health care for you and must be partially or fully disclosed to others outside of the organisation, depending on the circumstances. e.g: when referring to a specialist medical practitioner or when requesting blood tests, urine tests, x-rays etc; when itemising accounts for Medicare.

      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.