Patient Data Sheet Please complete using BLOCK LETTERS. Prefix MrMrsMissMs SURNAME FIRST NAME ADDRESS POSTCODE TELEPHONE (Home) TELEPHONE (Work) MOBILE EMAIL DOB AGE NEXT OF KIN TEL NO PRIVATE HEALTH FUND (HOSPITAL COVER) HOSPITAL COVER NUMBER VET/AFFAIRS NO MEDICARE NO NUMBER NEXT TO NAME ON M/CARE CARD EXPIRY REFERRING DOCTOR SUBURB TEL NO (if known) FAMILY DOCTOR (if different to the above) SUBURB TEL NO (if known) NAME AND ADDRESS OF PERSON RESPONSIBLE FOR PAYMENT OF ACCOUNT IF NOT SELF: COVID-19 Have you had your COVID-19 vaccinations?---YesNo If you have had your COVID-19 vaccinations please upload your vaccine certificate here Have you tested positive for COVID-19 at any point in time?---YesNo If you have tested positive for COVID-19 when was this? If you previously tested positive, have you had a negative COVID-19 test to confirm that you have recovered from COVID-19?---YesNo INFORMATION ABOUT FEES AND PRACTICE POLICY The cost of consultation is above the Medicare schedule fee. This means you will not recover the full fee after claiming from Medicare. Accounts are payable at the time of consultation.There may be additional charges for procedures undertaken (i.e Injection etc.). Any 'out-of-pocket' cost related to procedures need to be paid before the procedure date. Procedures will have to be rescheduled; otherwise. Any unpaid accounts for consultation or surgery will be sent to our debt collectors and you will be responsible for all fees incurred I have read the above and agree to abide by the payment terms of this practice. I consent to all or any of the above information to be released to other health providers, next of kin and agencies during the course of my treatment.