Patient Registration Forms

Patient registration forms

Do you want your appointment to go on the cancellation list?

Patient Information

The Patient's Information

Child's First Name

Child's Last Name

Child's Preferred Name:

Pronoun/s

Child's Date Of Birth:

Child Identifies as:

Male

Female

Non-binary

Other

Gender Assigned at Birth: (if different to identifies as)

Child's Address:

Address

Suburb:

Post Code:

Does the child identify as Aboriginal or Torres Strait Islander:

Yes

Prefer Not to Say

Parent/Guardian/Carer Information

Title:

First Name

Last Name

Date of Birth: (for Medicare)

Relationship to the Patient:

Phone/Mobile Number:

Postal Address:

Address:

Suburb:

Post Code

Interpreter Required?

Yes

If Yes, what language?

Secondary Contact

Name:

Relationship to the Patient:

Phone/Mobile Number:

GP Details

Usual GP:

The GP Clinic Name:

Where?

Suburb/Town:

State

Billing Details

Child's Medicare Card Number:

Parent's Medicare Card Number:

Child's IRN:

Parent's IRN:

Do you hold a current and valid Blue, Centrelink Pension Card? If yes, please upload a picture.

Yes

Child's CRN:

Please attach a copy of the Centrelink Pension Card. Please note Healthcare Cards are not applicable.

Choose File

School/Education/Care Details

Name of School or Centre:

Type of School (ie Primary School, Secondary School, Kindergarten, Child Care, Special Needs School)

Teacher's Name:

Year Level:

Email Contact:

Siblings

Does your child have siblings?

Yes

Name

DOB:

Name

DOB:

Name

DOB:

Name

DOB:

Immunisations

Are your child's immunisations up to date?

Yes

If available, please attach a copy of your child's immunisation record.

Choose File

Birth History

Complications in Pregnancy:

Delivery Type:

Birth Weight:

Complications after Birth:

Child's Medical History

Known Allergies:

Past Operations or Illnesses: Date and Details

Current Medication: (Name, How much is taken, and How often)

Family Medical History

Please use this space below to detail any significant medical conditions (physical or psychiatric) suffered by any close relative
(Grandparent, Parent or Sibling)

Detail any significant medical conditions (physical or psychiatric) suffered by any close relative

Terms and Conditions

Accounts and Fees - Terms and Conditions

Payment of an account in full is required on the day of the appointment/s (including telehealth).
The Account Holder accepts full liability for Medicare, Workcover, TAC and Health Fund claims which are rejected.
Monthly account keeping fees may be imposed on overdue accounts at the prevailing rate.
In the event of the Account Holder being in default of their obligation to pay and the overdue account is then
referred to a debt collection agency, and/or law firm for collection and the agency charges commission
on a contingency basis the Account Holder shall be liable to pay as a liquidated debt, the commission payable
by the Practice to the agency, fixed at the rate charged by the agency from time to time as if the agency
has achieved one hundred per cent recovery and shall apply.
In the event where the Practice or the Practice’s agency refers the overdue account to a lawyer the
Account Holder shall also pay as a liquidated debt the charges reasonably made or claimed by the lawyer on
the indemnity basis.
Accounts overdue by more than 30 days will be subject to interest prescribed by the Penalty Interest
Rates Act (Vic) plus 2% from the date payment is due until the date payment is made.
Reference to the Account Holder includes reference to his heirs executors and permitted assigns and where
there is more than one, shall include reference to each of them jointly and severally.
The Account Holder accepts liability for payment of all accounts incurred by the persons described above for the
period until the Account Holder advises in writing to the contrary.
Upon completion of this form, the person named as the Account Holder will be the person/s that has completed this form and agreed to these terms.

Privacy Consent

The full Geelong Paediatric Group Privacy policy can be viewed here and a printed version is available on request.

You as the parent/guardian of the above mentioned patient/child, understand that Geelong Paediatric Group collect and retain personal information about you and your child. You understand:

- the types of personal information collected by the Practice, the reasons why it is necessary to collect it and the circumstances in which your personal information may be used or disclosed;

- that I may request access to my personal information, which may be granted in accordance with the practice’s Access to Personal Information Policy. I will be provided with a written reason if access is denied;

- that you may request an amendment to the personal information if it is incorrect. You will be provided with a written reason if a request for amendment is denied;

- that your personal information will not be used for direct marketing or disclosed to overseas recipients;

- that you are not obliged to provide the Practice with your personal information, but withholding information may limit the Practice’s ability to provide you with full service.

- that you have the right to lodge a compliant about the handling of your personal information if you are dissatisfied, which will be dealt with in accordance with the Practice’s complaint handling procedure.

Agreement

By writing your name below, you accept the above terms and and conditions, and consent for information to be collected and held in accordance with legislation.

Full Name

Date Agreed: