New Patient Form

1

What is your name?* This field is required.

Prefix

First Name

Middle Name

Last Name

2

What is your preferred name?Feel free to leave this blank if the same as your first name

3

Date of Birth* This field is required.Please note Dr Nash is an adult endocrinologist.

4

Contact Number* This field is required.

5

Preferred email address* This field is required.Please note receipts & correspondence will be sent to this email

6

Please provide your availabilityYou can skip this section if you already have a scheduled appointment Dr Nash is available at Carlton North on Tuesdays between 1-5 PM. Dr Nash is available via Telehealth on Tuesdays & Thursdays between 9 AM to 8 PM. To assist you in scheduling your appointment, please provide your PREFERRED LOCATION (Carlton North or Telehealth) and PREFERRED TIME. Specifically, let us know if mornings or afternoons are best. This information will help our team find the best time for you.

7

Collection of Health Information and Consent* This field is required.

8

What is your address?* This field is required.

Street Address

Street Address Line 2

City/Suburb

State

Postcode

Country

9

What sex were you assigned at birth?

Male

Female

Other

Decline to answer

10

What pronouns do you prefer that we use when talking about you?

She/her/hers

He/him/his

They/them/theirs

Other

11

Do you identify as being of Aboriginal and/or Torres Strait Islander origin?

12

Emergency Contact / Next of Kin* This field is required.Please provide the name of your Emergency Contact or Next of Kin

First Name

Last Name

13

What is their relationship to you?* This field is required.

14

What is their best contact number?* This field is required.

15

What is their email address?

example@example.com

16

Who is your regular GP?

First Name

Last Name

17

What is the name of your regular GP Practice?Feel free to skip this if you're unsure

18

What is the street address of your regular GP Practice?Feel free to skip this if you're unsure

Street Address

Street Address Line 2

City/Suburb

State

Postcode

Country

19

Do you have a valid Medicare card?* This field is required.To be eligible for a Medicare rebate, it is necessary to present a valid Medicare card and referral letter for all appointments, including follow-ups. If you don't have a Medicare card or a valid referral letter, you can still consult with the Dr Nash, but you won't be able to claim the Medicare rebate.

YESNO

20

Medicare Details* This field is required.

Name on Card

Medicare Card Number

Individual Reference Number (next to name)

Expiry Date (MM/YYYY)

21

Do you have private health insurance with hospital cover?

YESNO

22

Private Health Insurance Details

Health Fund

Membership Number

Individual Reference Number

23

Do you have a current Health Care Card or DVA card?

YESNO

24

Concession Card Details

Card Number

Expiry Date

Health Care Card

DVA Gold Card

DVA White Card

Health Care Card

DVA Gold Card

DVA White Card

Card Number

Expiry Date

Card Number

Expiry Date

Card Number

Expiry Date

25

Dr Nash welcomes all patients regardless of whether they have a referral letter, Medicare card, or private health insurance.

There is, however, important information we must make you aware of prior to your visit.

Do you have a valid referral letter?

To be eligible for a Medicare rebate, you must have a Medicare card and a valid referral letter. Generally, referrals from GPs are valid for 12 months, while referrals from other specialists are valid for 3 months. If you don’t have a referral letter or your existing one has expired, you will need to obtain a new referral to be eligible for a Medicare rebate, regardless of whether you are seeing Dr Nash for an initial consult or a review appointment. If you are unsure whether your referral has expired, please contact our team on 03 9114 8780 or hello@drbennash.com.au to check.

Overseas Health Insurance

For patients who do not have a Medicare card, a rebate for the consultation may be available from your overseas health insurance (e.g., BUPA). We do not require you to have a referral and we will provide you with an invoice on the day of your consultation so you can submit a claim to your health fund. Please note that pathology tests are not included in our fees and are billed directly by the pathology company. You may receive a private invoice from the pathology service, which might be covered by your overseas health insurance.

26

Do you have a valid referral letter?

Yes, I have a physical copy and am able to upload it here

Yes, my referring doctor will send it directly to you

No, I do not have a referral letter, but will send one through prior to my appointment

No, I do not have a referral letter, but I am eager to proceed even without the Medicare rebate

27

Please upload your referral letter/sPlease upload your GP or other specialist referral letter. If you have recent pathology or imaging results related to your referral you can upload them here. Please note the maximum file size is 10.6MB.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

28

Is your referring doctor your regular GP?

YESNO

29

What is the name of your referring doctor?

First Name

Last Name

30

What is the name of your referring doctor's practice?Feel free to skip this if you're unsure

31

What is the address of your referring doctor's practice?Feel free to skip this if you're unsure

Street Address

Street Address Line 2

City/Suburb

State

Postcode

Country

32

What is your occupation?

33

Do you have any allergies?

YESNO

34

Please list your allergiesPlease include the type of reaction if known

35

Medical HistoryPlease list any medical conditions you have (including year of diagnosis if known)

36

Surgical HistoryPlease list any operations/surgeries you have had in the past (include year of surgery if known)

37

Current MedicationsPlease include NAME, DOSE, and FREQUENCY (e.g. metformin 500mg twice daily)

38

Signature* This field is required.Thank you for taking time our to complete this form. It will be reviewed by Dr Nash before your first appointment. Please sign below prior to submitting this form.

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