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 apointment.

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

Title:e.g. Mrs/Ms/Mr/Dr if applicable

Patient First Name *

Patient Last Name *

Preferred Name (if different from above)

Date of birth *

Address: *

Street address *

City *

State *

Postcode *

Contact phone number (e.g. mobile) *

Additional phone number (e.g. home)

Email verification *

Send code

Please verify your email address before continuing. If you do not have an email address, please contact ENT North 1300 357 338

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

NoYesNot applicable (adult patient)

If YES, a copy must be provided to ENT North before consultation.

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

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

NoYesMy GP has sent this on my behalf

If NO, a copy must be provided to ENT North before consultation.

Please upload your referral here

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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.

Do you (the patient) have a Medicare Card? *

NoYes

Medicare number: *

Reference:

Expiry date:

Do you (the patient) have private health insurance? *

NoYes

*Hospital Cover only

Name of fund: *

Membership Number:

Ref number:

Do you (the patient) have a BLUE Pension Card? *

NoYes

Pension Number: *Please bring your card with you on the day of your appointment as our reception staff will need to sight your card.

Do you (the patient) have a DVA Card? *

NoYes

Veterans Affairs number: *Please bring your card with you on the day of your appointment as our reception staff will need to sight your card.

Colour of Card: *

Who is your usual General Practitioner (GP)?

GP's name: *

Medical Practice: *

Medical Practice address:

Medical Practice Phone number

Do you see a dentist or other specialist that would be of interest to the ENT surgeon? *

NoYes

Please list their name and medical practice details below:

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

NoYes

Upload any relevant documents or reports here

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alternatively, you can email these to: reception@entnorth.com.au

Person responsible for the account

Who is responsible for the account? *

Me (the patient)Other (parent/guardian/other for patient's under 18 years)

Name of person responsible for the account:

Relationship to patient:

Account holder's date of birth:

Medicare reference number:

Account holder's address:If different to the patient's address

Emergency Contact

Emergency contact name: *

Relationship to you (the patient): *

Emergency contact mobile number: *

Emergency contact home/work/other number:

Are you happy if we communicate with you by SMS *

NoYes

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

NoYes

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

NoYes

How did you hear about ENT North? *

GPInternetFriend (word of mouth)

Privacy Information and Consent Form

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. *

Signed: *

Draw signature|Type signatureClear

Acknowledged and Signed by: (your full name) *

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