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Mater Private Clinic, Suite 7, 16 Weippin Street, Cleveland |
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City Road Specialist Centre, 105 City Road, Beenleigh |
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Hospital Specialist Suites, 259 McCullough Street, Sunnybank |
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| Surname* |
Given Name* |
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| Date of Birth (DD-MM-YYYY)* |
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| Address |
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| Contact Numbers (H) |
(W) |
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| Mobile* |
Email* |
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| Medicare Number |
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Expiry Date |
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| Private Health Fund |
M'ship Number |
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| Veterans Affairs Number |
Colour of Card |
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| Pension Number |
Expiry Date |
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| Occupation |
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| Name of referring doctor* |
Regular GP |
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I hereby accept responsibility for payment of my account.
This form contains personal information about you which is collected by this Practice for the provision of the best health care for you. This information may be used in relation to your health care, an insurance claim or any other matter relating to your health care. This information may be disclosed to other service providers, a statutory health authority, insurers, debt collectors or other health practitioners. You have the right to see any health information we hold about you as well as the ability to correct any details that not accurate. Completion of this form implies you consent to the use and storage of the information it contains.
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| For workers compensation or insurance claims please complete this section |
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| Insurance Company |
Claim Number |
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| Injury Date |
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| Are you entitled to Worker Compensation? |
| Yes
No
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| Please state your Workers Compensation Claim Number: |
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| Please state the name and address of your employer: |
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| I hereby accept responsibility for payment of my account if Work Cover or Health Fund rejects my claim. |
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| Signature: |
Date: |
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| Enter the code as it is shown:* |
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