• New Patient Form

  • Date of Birth: *
     / /
    2 digit day, 2 digit month, 4 digit year
  • Format: 0000000000.
  • Sex:*
  • Do you have Medicare Card?*
  • Do you have Private Health Insurance:*
  • Do you have a Veterans Affairs Card?:*
  • Are you on Aged Pension:*
  • Are you on Disability Pension:*
  • Next of Kin & Emergency Contact Details

  • Format: 0000 000 000.
  • Can we leave a message to the NOK, if required:*
  • Format: 0000 000 000.
  • General Practitioner Details:

    If different from referring doctor
  • Is your regular GP different from the referring doctor?
  • Person Financially Responsible:*
  • Rows
  • Rows
  • Medical and Surgical History

    To help us provide you with the best possible care please answer the following questions.This information will be kept in your file and treated as confidential (see privacy policy).
  • Rows
  • Do you have any family history of any of the above?*
  • Rows
  • Are you on recreational drugs?*
  • Do you Smoke?*
  • Do you drink alcohol?*
  • I consent to being contacted regarding research projects that South Eastern Specialist Centre participate in:*
  • Patient Consent

    Privacy and Confidentiality
    The information you provide will be treated confidentially and handled in accordance with applicable privacy legislation. Confidentiality may need to be breached for reasons of safety, such as where there is a risk of harm to yourself or others. This would usually occur with your knowledge where possible.

    It is often beneficial for your care for there to be communication between your treating clinician/specialist, other health professionals, and support people nominated by you. This communication would occur with your permission and involvement where appropriate.

    Emergency and After-Hours Care
    South Eastern Specialist Centre does not provide an after-hours or emergency service. Although we endeavour to respond as soon as possible during business hours, we may not be able to respond immediately.

    If you require urgent medical attention or emergency intervention, please contact your General Practitioner or their after-hours service, call 000, or present to your nearest Emergency Department.

    For mental health crisis support, you may also contact Monash Health Psychiatric Triage on 1300 369 012 or Lifeline on 13 11 14. Crisis Assessment and Treatment Teams may provide after-hours telephone support, home visits, or arrange admission to a public hospital where clinically appropriate.

    Appointments
    Our clinic will send you an SMS reminder for your upcoming appointment, generally 72 hours prior. Please ensure you arrive on time. Failure to do so may result in a shorter consultation.

    If you need to cancel, we require a strict minimum of 3 business days’ notice. If you provide less notice, or if you fail to attend your appointment, you may be charged a non-attendance fee. This fee is a fully out-of-pocket cost and cannot be claimed through Medicare, DVA, WorkCover or TAC. No further appointments will be offered until this fee is paid in full.

    Our practice endeavours to run on time for appointments as much as possible as we appreciate your time is valuable, however, at times we may be running behind schedule.

    Referrals
    It is your responsibility as the patient to ensure that you have a valid referral where one is required for Medicare claiming. Without a valid referral where required, you may not be eligible for Medicare benefits. GP referrals generally last 12 months and specialist referrals generally last 3 months.

    Script Requests
    Prescriptions requested outside of your consultation will be actioned at the treating clinician’s discretion. Such requests may incur a private fee and may not be Medicare-rebatable.

    Document Requests
    Requests for medical reports or documents, including NDIS, travel, work, university, insurance, legal or similar reports, will be considered upon request and may incur a private fee. These requests may not be Medicare-rebatable.

    Telehealth
    If you attend by telehealth, you confirm that you will be located within Australia at the time of the consultation, where this is required for the service.

    Bulk Billing / Assignment of Medicare Benefit
    Where a service is bulk billed, I assign my right to the Medicare benefit payable for that service to South Eastern Specialist Centre and/or the named provider/practice. I understand the provider/practice may receive the Medicare benefit directly and accepts it as full payment for the applicable bulk billed service.

    AI Scribe Consent
    I consent to the use of an AI scribe during my consultations to assist with clinical documentation. I understand I may ask questions about this or withdraw my consent at any time.

    Authority to Obtain and Share Clinical Information
    By signing below, I authorise the clinicians, specialists and providers at South Eastern Specialist Centre to obtain relevant letters, reports and investigation results, and to communicate with my GP, referrer, other treating health professionals and nominated support people as clinically appropriate.

  • Date*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Should be Empty: