Patient registration

Please complete the patient registration form prior to your appointment at ENT North.

If you are unable to complete the form online, please contact our reception team on 1300 357 338 to receive a hardcopy or PDF version.

Alternatively, please arrive 10 minutes prior to your appointment to complete the form on the day of your appointment.

This registration form will take approximately 5-8 minutes to complete.

Personal Information

Patient first name

Patient surname

Patient preferred name

Date of birth

Email

Contact phone number

Additional phone number

Apartment/ Unit etc

Street Address

Suburb

State

Post code

Are there any Custody/Court orders related to your child/the patient?

NO YES Not applicable (adult patient)

IF YES, A copy must be provided before your appointment. Upload below or email to reception@entnorth.com.au

Have any of the patient's siblings, parents or partners been patients of ENT North previously?

NO YES

If YES, please provide the name of the relative below:

Medical Information

Does the patient have a Medicare Card?

NO YES

Medicare Card Number

Patient reference number

Expiry date

Does the patient have private health insurance? (Hospital cover)

NO YES

Name of Fund:

Membership Number:

Patient Ref Number

Does the patient have a BLUE Pension Card?

NO YES

Pension Number:

Does the patient have a DVA Card?

NO YES

Veteran Affairs Number:

Colour of Card

General Practitioner and other Specialists

Have you sent ENT North your referral to see our ENT surgeons?

NO If NO, a copy must be provided to ENT North before consultation. YES My GP has sent this on my behalf

Upload Referral

Alternatively, you can email this to: reception@entnorth.com.au *please note: a valid referral is within 12 months (GP referral) or 3 months (specialist referral) from the date of the referral.

Who is your usual General Practitioner (GP)?

Medical Practice Name

Medical Practice Address

Medical Practice Phone

Does the patient have a Dentist?

NO YES

Please list their name and dental practice details below

Are you under the care of any other medical or surgical specialists?

NO YES

If so, please list

Would you like to attach any investigations or reports for your ENT doctor?

NO YES

Upload Reports

Person Responsible for Account

Who is responsible for the Account?

I am the patient (I AM OVER 18 YEARS OF AGE) I am the parent/guardian/other (FOR PATIENT UNDER 18 YEARS OF AGE)

Emergency Contact

Emergency contact name

Relationship to the Patient

Emergency contact mobile number

Emergency contact home/work/other number

Communication

Are you happy if we communicate with you by SMS?

NO YES

Are you happy for us to email your results when appropriate?

NO YES

Are you happy for us to collect information about the areas of your care for quality improvement and audit purposes?(No names are disclosed)

NO YES

Privacy and Consent

The law gives you certain privacy rights in relation to information that you give to this medical practice. We need your consent to collect personal information about you. The fact that you have come here implies that you consent to us knowing about your health situation either for an event or generally. This form explains your rights in relation to the use of the information and, how we may disclose it to other medical service providers.

The information we ask you to give us is deeply personal. However, not having it will restrict our capacity to provide you with the standard of medical care that you expect.

Please carefully read the following information about privacy issues and then sign this form. It will go on your file and you may examine it or change it at any time.

We collect information from you mainly to assess, diagnose and treat your illness properly and be pro-active in your health care. We will also use the information you provide in the following ways:

Administration of this medical practice;
Billing, including compliance with Medicare and Private Health Fund requirements;
Disclosure to others involved in your care, including doctors, specialists & healthcare providers outside this practice who may become involved in treating you. This may occur through referral to other doctors, or for medical tests and, in the reports returned to us following the referrals. If necessary, we will discuss this with you;
Participate in the Australasia Society of Otolaryngology Head & Neck Surgery (ASOHNS) National Surgical Audit, for the purpose of ensuring our doctors are providing appropriate care of adequate quality compared to our professional’s standard.

I-Scribe is used in this practice

ENT North uses I-Scribe an automatic transcription service Specialist Doctors use to capture the consultation and transcribe medical notes.

Patient Acknowledgement

Please read and tick the acknowledgements below

I have read this form and understand why collecting information about me is necessary. I am also aware that this practice has a privacy policy for managing patient information.

I understand that I am not obliged to provide any information requested of me. I also understand that failure to provide this medical practice with all the information it needs may restrict the ability to provide the quality of health care and treatment that I require.

I am aware that I have the right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances. I understand that if my information is to be used for any purpose other than that set out above, my permission, in writing, will be sought before any action is taken.

I acknowledge that I have read this form before signing it and, that a member of staff of this practice has, at my request, clarified any aspects of it that I did not at first understand.

Consent For Release Or Acquisition Of Medical Information/Records

I hereby give my permission for Dr Amott and other ENT NORTH Associates to either release or request any medical information/records relevant to me as required.

Type full name to sign

I agree to the terms and conditions listed above

Patient registration

Please complete the patient registration form prior to your appointment at ENT North.

Personal Information

Medical Information

General Practitioner and other Specialists

Person Responsible for Account

Emergency Contact

Communication

Privacy and Consent

Patient Acknowledgement

Consent For Release Or Acquisition Of Medical Information/Records

Thank you for completing this online form. Please press the submit button below to send to ENT North.

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