Patient Registration | DR JUSTIN TUCKER

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Welcome to Prologue!

The whole team here at Prologue thanks you for giving us the opportunity to join you for your pregnancy. Communication is a vital part of providing excellent care and you filling in this form will allow us to communicate with you and with your permission, the rest of your team. We look forward to caring for you in every way possible.

See you soon!

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PLEASE ENTER YOUR FULL NAME* This field is required.

First Name

Last Name

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PLEASE ENTER YOUR DATE OF BIRTH

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PLEASE SUPPLY A POSTAL ADDRESS* This field is required.

Street Address

Street Address Line 2

City

State

Postal Code

Country

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PLEASE PROVIDE YOUR EMAIL ADDRESS* This field is required.

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WHAT IS YOUR PREFERRED CONTACT NUMBER?* This field is required.

Please enter a valid phone number.

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ARE YOU COVERED BY MEDICARE?* This field is required.

YESNO

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PLEASE PROVIDE YOUR MEDICARE DETAILS* This field is required.

Medicare number

Reference number

Expiry month

Expiry year

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WE WILL NEED A REFERRAL FROM YOUR GP TO CLAIM A MEDICARE REBATE FOR YOU* This field is required.

I CAN UPLOAD THIS NOWI WILL EMAIL THIS LATER

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PLEASE EMAIL YOUR REFERRAL TO adminsupport@prologue.com.au BEFORE THE FIRST APPOINTMENT

OK, GOT ITI PREFER TO UPLOAD IT NOW

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USING THE BUTTON BELOW, PLEASE UPLOAD OR TAKE A PHOTO OF YOUR REFERRAL ALONG WITH ANY RELEVANT RESULTS YOU MAY HAVE* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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DO YOU HAVE A PRIVATE HEALTH INSURANCE?* This field is required.

YESNO

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PLEASE SELECT YOUR PRIVATE HEALTH FUND* This field is required.

Private health fund

Membership number

Reference number

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DOES YOUR PRIVATE HEALTH POLICY COVER OBSTETRIC CARE?* This field is required.

YESNO

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DO YOU HAVE A PARTNER OR SOMEONE ELSE SIGNIFICANTLY INVOLVED IN YOUR CARE?

YESNO

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If a partner or someone else significant is involved in the care that I will be providing for you, I would like them to feel included in our correspondence. Please provide their important details below.

First name

Last name

Mobile

Email

Date of birth

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OTHER THAN YOUR GP, IS THERE ANY MEDICAL PRACTITIONER OR PROFESSIONAL SUCH AS A NATUROPATH OR ACUPUNCTURIST YOU WOULD LIKE ME TO KEEP UPDATED ON YOUR PROGRESS?

YESNO

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PLEASE COMPLETE THEIR DETAILS BELOW* This field is required.

First name

Last name

Email

Address

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YOUR PRIVACY

Prologue collects information from you for the primary purpose of providing quality care. Providing us with your personal details and medical history allows us to properly assess, diagnose, treat and be proactive in your health care needs.

Prologue will use the information you provide in the following ways:

Administrative purposes in the running of our medical practice.
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements
If permitted by you, update any other health professionals involved in your health care on your progress and our plan. Prologue will make sure that your personal details will remain confidential in accordance with the NSW Privacy and Personal Information Protection Act 1998.

By signing below, you agree that:

You are happy for your treating Prologue team to discuss your medical history, diagnosis, and management plan with your referring doctor and any other relevant medical specialists as required
You understand you are welcome to access your medical records at Prologue
You are responsible for and understand the fees associated with your care
By agreeing, you consent to receive Prologue communications and updates, which you can opt out of at any time.
The information you have supplied is accurate

If your information is to be used for any purpose other than the above, your consent will be sought.

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Signature* This field is required.

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