New Patient Registeration - The Kidzz Practice

New Patient Registration

Patient Details

First name

Middle name

Surname

Preferred Name (If Any)

Patient Gender

Date of Birth

Street Address

Suburb

State

Postcode

Postal Address (if different)

Cultural Background

This information is optional, but assists us to provide relevant healthcare that meets your needs.

Indigenous Status

Ethnicity

Knowing this information will help us provide relevant healthcare that meets your needs.

Patient Medicare Card Details

Medicare Card Number

Reference Number (IRN)

Expiry

First Parent / Guardian Details (Primary Contact)

Title

First Name

Last Name

Relationship to Patient

Contact Number

Email Address

Second Parent / Guardian Details (Secondary Contact)

Title

First Name

Last Name

Relationship to Patient

Contact Number

Email Address

Consent

I confirm that the above information provided is true, complete, and accurate. I am aware that I am responsible for payment of the agreed consultation fees at the end of the consultation. I agree to a cancellation fee of $100.00 if an appointment is cancelled within 48 hours of the agreed time, and a fee of $100.00 for any out of appointment requests (unless agreed in advance). I am aware that all information provided will remain confidential.

I consent to being contacted by the practice

I consent to the collection of patient information

This consent (if provided) allows us to attempt to obtain relevant reports from other healthcare providers which are relevant to your child's care.

I consent to the use of computer systems

Name of person consenting to the above statements

This consent is for the use of use certain privacy protected third-party computer systems (such as AI transcription services) to increase the quality of the care we provide.

Patient Details

First name

Middle name

Surname

Preferred Name (If Any)

Patient Gender

Date of Birth

Street Address

Suburb

State

Postcode

Postal Address (if different)

Cultural Background

This information is optional, but assists us to provide relevant healthcare that meets your needs.

Indigenous Status

Ethnicity

Knowing this information will help us provide relevant healthcare that meets your needs.

Patient Medicare Card Details

Medicare Card Number

Reference Number (IRN)

Expiry

First Parent / Guardian Details (Primary Contact)

Title

First Name

Last Name

Relationship to Patient

Contact Number

Email Address

Second Parent / Guardian Details (Secondary Contact)

Title

First Name

Last Name

Relationship to Patient

Contact Number

Email Address

Consent

I consent to being contacted by the practice

I consent to the collection of patient information

This consent (if provided) allows us to attempt to obtain relevant reports from other healthcare providers which are relevant to your child's care.

I consent to the use of computer systems

Name of person consenting to the above statements

This consent is for the use of use certain privacy protected third-party computer systems (such as AI transcription services) to increase the quality of the care we provide.