Personal Information

Title *

Given Name *

Surname *

Preferred Name

Date of Birth *

Occupation

Mobile *

Phone

Email *

Street Address *

City *

State/Province *

Post Code *

Next of KIN / Emergency Contact

Name *

Relationship *

Phone *

Street Address

City

State/Province

Post Code

Medical Card Information

Medicare Card No. *

Ref No. *

Expiry Date0 / 7

Veteran's Affairs (DVA) Card No.

GoldWhite

Expiry Date

Private Health Insurance (Hospital Cover)YesNo

Health Fund Name *

Membership No. *

Level of Cover *

Date Joined *

Name of contributor (if not the patient)

Is there copayment/hospital excess on your policy?YesNo

Has your health insurance cover changed in the last 12 months?YesNo

Card No. *

Health Fund Validity *0 / 7

Do you currently have a claim?YesNo

Workers Compensation / Third Party / Public Liability

Name of Insurer *

Cause of injury *

Date of injury *

Case Manager *

Phone *

Email *

GP/Referring Doctor (must be complete to ensure correspondence is sent back to your usual doctor)

Full name of usual GP *

Practice/Clinic Name *

Street Address

City

State/Province

Post Code

Full name of referring Doctor (if different from above)

Practice/Clinic Name

Disclosure of your personal information

You acknowledge that where you provide your personal information (including sensitive information, such as health information) to us, it will be shared across by us and, affiliated health providers or other healthcare professionals as required in undertaking your care, and to ensure continuity of service in providing medical treatment and care to you. If you do not agree to us sharing your personal information across its related entities, affiliated health providers and other health professionals, we may be unable to provide services to you or we may be limited in the type or quality of services that we provide to you. Details on the collection, storage and use of your personal information by us and its related entities is set out in our privacy policy available online at: www.ramansethi.com.au

Financial Consent

You acknowledge that the patient or nominee named herein undertakes to pay the patient payment of the total amount on each attendance or any outstanding balance if your insurer or other payer does not cover the full costs of the consultation/treatment.

New Patient Registration

Welcome!

Personal Information

Next of KIN / Emergency Contact

Medical Card Information

GP/Referring Doctor (must be complete to ensure correspondence is sent back to your usual doctor)

Your Easy Registration Steps

Why Register in Advance?

Contact Us