Patient Registration Form

Williamstown

Patient Details

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Emergency Contact Details


If patient is under 18 years, please include date of birth and Medicare number of account holder for billing purposes.


DVA


Private Health Insurance (Hospital Cover)


WorkCover / TAC Claims


Regular GP Details


Information for Consultation


Medication


Allergies


Medical History


Anaesthetic


Fee Policy


This is a private billing practice and therefore full payment of fees are required on the day of your consultation(s). If surgery is required, a written Informed Financial Consent will be provided to you prior to your procedure which will outline your surgeon’s fees. These fees are required to be paid at least one week prior to your procedure. In the event that your overdue account is referred to a collection agency and/or law firm, you will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand costs. By signing this form you are agreeing to the above fee policy. Please speak to the receptionist prior to your appointment should you not be in agreement. I have read and understand the above statement.

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Privacy Policy


This practice collects your information in order to identify your medical record and provide an accurate, quality health service. I consent to the collection of my personal information for the purposes of administration, billing and disclosure to others involved in my medical care outside of this practice, for the purpose of ongoing health care.

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North Melbourne ENT

We are ear, nose and throat surgeons based in North Melbourne and Williamstown.

North Melbourne
Address: 
100/30 Wreckyn St, North Melbourne VIC 3051

Phone: (03) 9078 8074
Fax: (03) 9078 8105

Williamstown
Address: 54 Electra Street, Williamstown VIC 3016
Phone: (03) 9397 5507
Fax: (03) 9397 6914

© North Melbourne Ear, Nose and Throat.