Patient Registration

"*" indicates required fields

Name*

Prefix First Last

Date of Birth

Occupation

Address

Street Address Suburb Post Code

Home phone

Mobile phone*

Email*

Medicare number

Reference number

Expiry

Pension card number

Expiry date

Private Health Insurance

Yes

Time with health fund less than 12 months:

Yes

Fund Name

Membership Number

Next of kin/ Primary caregiver / Emergency contact / Account holder

Name

First Last

Relationship

Contact number

Date of birth

Referring Doctor

Name

Prefix First Last

Clinic name

CC: copy to additional doctors:

Primary concern to see Doctor:

Upload GP/Specialist Referral here:

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Consent

I agree to Dr Eric Levi & Melbourne ENT Airway Clinic passing on my personal details and medical information to other clinicians, hospitals and medical services if necessary for my care. I also consent to the release of health information (including test results, etc) about past and present illness to the doctor making this request. I understand this is necessary for my ongoing treatment.

Signature

Name*

Relationship

Date:*

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