Patient Registration - Dr Peter Walker

Name

Title First Last

Sex:

Male
Female

Date of birth:

Age:

Occupation:

Address:

Street Address City State Post code

Telephone (primary):

Telephone (other):

Email:

I consent to receiving electronic communication from this practice :

Yes

Next of kin:

Relationship to patient:

Contact number:

GP Name (if different to referring doctor):

Suburb:

Physiotherapist Name:

Suburb:

Medicare number:

Expiry date:

Reference number:

Are you in a Private Health Fund?

Yes
No

Health Fund name:

Health Fund number:

Do you have a DVA Card?

Yes
No

DVA Number:

File upload

Please upload associated files here:

Please upload GP referral, test result reports (x-ray, MRI, bone scan, ultrasound etc..), relevant doctors letters or any other relevant documentation.

Drop files here or

Max. file size: 64 MB, Max. files: 8.

Emails

Email Consent: (We aim to be as paperless as possible)

I give permission for the office of Dr Peter Walker to email any relevant medical records to: Medicare, Health Fund, Insurance Company (if applicable), Solicitor (if applicable), General Practitioner, Specialist Doctors, Physiotherapist, Hospitals, any medical personnel involved directly in your medical care.

Yes
No

Privacy Consent

Permission is given to collect and release information on my medical history in order to provide appropriate healthcare. In addition I understand certain information may be used for medical research and audit purposes. Click here to view our Privacy Policy.
Account: I understand that it is my responsibility to pay my account at the time of my consultation. I undertake to pay any addition expenses incurred in recovering overdue fees.

Consent*

I agree to the privacy policy.

Signature*

Date

Parent / Guardian Consent

Is the patient is less than 18 years of age?

Yes
No

I agree to the above terms and conditions:

Yes
No

Name*

First Last

Signature

Date

Worker's Compensation / Third party

Workers Compensation / Third Party I declare that this is an accepted insurance company claim. I understand if the claim is declined I must pay the consultation cost expected at the time of consult. If at any stage the claim is denied I must pay any outstanding accounts.

Signature

Date

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Patient Registration Form

File upload

Emails

Privacy Consent

Parent / Guardian Consent

Worker's Compensation / Third party