Patient Information Form - Dr Marcia Bonazzi

Patient Information

Details as they appear on your Medicare Card.

Title *

Surname *

Given Name *

Date of Birth *

Address *

Suburb *

Postcode *

Home Phone

Work Phone

Mobile *

Email *

Occupation

Happy to receive email correspondence? *

YesNo

Where did you hear about us?

Any Allergies (Please List)

Billing Information

Add to My Health Records register? *

YesNo

Medicare Number *

Ref No *

Pens./HCC No

Expiry Date *

Private Health Insurance

Referral Details

Referring Doctor Name

Date of Referral

Local GP Name (if different)

Local GP Phone

Next of Kin Details

Next of Kin Full Name

Relationship

Home Phone

Mobile

Date of Birth

Consent & Signature

We require your consent to collect personal information about your medical history. Please read the information below carefully.

Privacy Statement

All Information collected by this practice will be used for providing healthcare and will be compliant with the 2001 Health Records Act. This medical clinic collects information from you for the primary purpose of providing quality health care. We require your personal details and a full medical history to properly assess, diagnose, and treat your health care needs.

Information Usage

Administrative purposes in running our medical practice.
Billing purposes including compliance with Medicare and Health Insurance Commission requirements.
Disclosure to others involved in your health care, including treating doctors and specialists.

Billing Consent & Policy

I understand and acknowledge that I am responsible for payment of my consultations on the day and for all other associated medical fees for my care. In the event that an invoice remains unpaid, we may engage a debt collector to collect the debt and add any commission charged to your overall debt.

FULL NAME *

Signature *

Date

Dr Marcia Bonazzi