NEW PATIENT REGISTRATION FORM

If you are a new patient, for your convenience you can complete the new patient registration form online prior to your first visit.

Your selected specialist is Mr Otis Wang

Patient Information

Please provide your first name.
Please provide your last name.
Left
Right
Both

Next of Kin

Referring Doctor

Other Doctors / Practitioners involved in your care

Local Doctor

Physiotherapist or other practitioners involved in your care

Private Health Insurance (Do you have health insurance coverage for a private hospital)

Veterans' Affairs

Workcover/TAC/COMCARE

Medical History

Smoker
High Blood Pressure
Diabetic
Heart Disease
Cancer

Do you take any of the following medications

Warfarin
Plavix
Iscover
Clopidogrel
Prednisolone
Aspirin
Methotrexate
Insulin

Fees & Information Consent

Payment for your consultation is required on the day of service. We accept Cash, Cheque, Eftpos, Visa or Mastercard. (Amex and Diners are not accepted). A portion of the consultation fee is rebatable from Medicare (if eligible) and we are able to claim this directly for you with Medicare online.

If surgery is required, you will be provided with an Estimate of Fees.

There usually is a personal Gap Payment (dependent on your insurance cover) and this is payable five working days prior to the procedure.

  • I understand and accept that it is my responsibility for payment of specialist’s fees in relation to my medical care.
  • I understand and accept that if any third party insurer (e.g. Health Fund/Workcover/TAC/Comcare) refuses to pay my claim in relation to my medical care, I am personally responsible for payment of your specialist's fees.
  • I understand and accept that if any overdue accounts are referred to a debt collection agency and/or law firm for collection that I will be liable for the recovery costs & commission incurred.
Please agree to the MOS terms.

Information Consent

We require your consent to collect personal information about you. Please read this information carefully, and sign where indicated below.

This medical practice collects information from you for the primary purpose of providing quality health care.

We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs.

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

This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals.

  • I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information.
  • I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me.
  • I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.
  • I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.
Please give your consent.