Patient Registration Form

Patient Registration Form
Patient Information
Patient name:*

TitleFirst NameMiddle NameLast NamePreferred Name
Date of birth*
DD/MM/YYYY
Sex of patient:*
Patient address:*

Street Address

Street Address Line 2

CityState

Postcode
Patient occupation:
Phone number (H):
Phone number (M):*
Phone number (W):
Email:
Are you of Aboriginal or Torres Strait Islander origin?*
Medicare / Private Health Insurance Information
Medicare number:*
Medicare ref number:*
Do you have private health insurance?*
Who is your Private Health Insurance with?:*
Private Health Insurance No:*
Private Health Insurance Level of cover:*
Do you have a pension card?*
Pension Card Number:*
Pension Expiry Date:*
Do you have a DVA Card?*
DVA No:*
DVA Card Colour:*
Health Provider Information
General practitioner name:*

First NameLast Name
Clinic name:*
Clinic address:

Street Address

Street Address Line 2

CityState

Postcode
Emergency Contact / Next of Kin Details
Emergency contact name:*

First NameLast Name
Relationship to patient:*
Contact phone number:*
Email:
Medical History
Current medications:*
Please provide a comprehensive list
Medical conditions & previous operations:*
Please provide a comprehensive list
Do you have any allergies?*
Allergy information:*
Please list and tell us about your reaction
Are you diabetic?*
Informed Financial Consent
Effective as of 1st July 2025

	Urologist Fee	Medicare Rebate	Out Of Pocket (Gap)
Initial Consult (104/91822)	$300	$86.15	$213.85
Review Consult (105/91823)	$200	$43.35	$156.65
Initial Consult (Pension Rate*)	$210	$86.15	$123.85
Review Consult (Pension Rate*)	$150	$43.35	$106.65

Payment for your consultation is expected on the day of service. If you are having a telehealth or phone consultation payment is expected in advance. A debt recover fee of 20% + GST will apply for outstanding accounts.

A current referral is required for you to claim Medicare rebates. Please note that a referral from a General Practitioner is generally valid for 12 months but may be deemed ongoing or indefinite if specified by your GP.

A referral from a specialist is valid for only 3 months. DVA Gold Card holders will be billed directly through the Department of Veterans’ Affairs. If nursing services are required (in the rooms), a non-rebateable fee may apply. A $20 non-rebateable fee will apply for prescriptions requested outside of appointment time.
Consent for release of information
In accordance with the Australian Privacy Principles contained in the Commonwealth Privacy Act 1988 and applicable State legislation.

Advanced Urology Melbourne respects your right to privacy and thus has systems and processes in place to ensure it complies with the Australian Privacy Principles. This statement is a summary of the practice’s privacy policy.

Advanced Urology Melbourne collects information about you for the purpose of providing health services to you. Personal information such as your name, address and health insurance details are used for the purpose of addressing accounts and sending relevant correspondence, as well as processing payments and writing to you about our services and any issues affecting your health care.

Advanced Urology Melbourne may disclose your health information to other health care professionals, your emergency contacts, or third parties, or require it from them if, in our judgement, it is necessary in the context of your care. Please notify the practice if you would like to add additional contacts to your medical care team.
Please sign this form as confirmation that you have read and understand our Privacy Policy, and consent to the use of your information in the ways outlined.
Patient signature*

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Date signed:*

DayMonthYear
Date Signed
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Patient Information

Medicare / Private Health Insurance Information

Health Provider Information

Emergency Contact / Next of Kin Details

Medical History

Informed Financial Consent

Consent for release of information