Patient Registration and Consent Form

New Patient Registration

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  • KIN DETAILS

  • I give permission to register with Medicare for the purpose of validating Medicare No & Item no to bulkbill the consult. This Medical Practice collects information for the primary purpose of providing quality healthcare. We require your personal details and full medical history to allow us to properly assess, diagnose, treat and advise on all your health needs. By signing this document, you are giving permission for your health information to be shared with others involved in your health care, such as treating doctors and specialists within or outside the practice. You are also giving consent to provide de-identified information for quality improvement and research projects. This practice participates in National and State recall and reminder systems.











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