New Patient Registration Form

Full Name

First NameMiddle NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Postal Address if different from above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Gender

Weight (kg)

Height (cm)

Emergency Contact Name

First NameLast Name

Emergency Contact Relationship

Emergency Contact Number

Please enter a valid phone number.Format: (000) 000-0000.

Occupation

If retired what was your previous job

Medicare Number

Medicare Line Number

Medicare Expiry Date

Date

Ethnicity

Medical History (previous surgeries, diagnoses etc)

Current Medications

GP Details - Name and suburb

Perioperative patients only - Please put the date of your upcoming surgery

Perioperative patients only - What procedure do you have planned?

DVA Number

DVA Colour Card

Health Fund Name

Health Fund Number

My Health Record- Do you consent to information being shared on your My Health Record?

Other Health Professional Specialist

Do you smoke?

Do you drink alcohol?

Do you take Recreational drugs?

How many of the above?

iScribe AI Technology-Dr Vohra uses AI based technology for note taking. It is secure and your data is protected.

BGB Healthcare Clinic charge an out of pocket 'Gap' payment for the Doctor's consultation. By signing this form you are consenting to informed financial consent. The Gap fee is not covered by your private health fund. Medicare rebate will be applied and a portion of the payment will be refunded back into your bank account linked with Medicare. Initial consultation with the Doctor is $280 and follow up is $150. Full details on the prices for the Doctor's appointments is on our website www.bgbhealth.com.au.

Perioperative patients will be bulk billed by Medicare. Surgical patients may be contacted by our Nurse Practitioner before and/or after surgery. This payment will be bulk billed through Medicare. When signing this form you consent to BGB billing Medicare on your behalf for both the Doctor and Nurse Practitioner services. Should you have any questions about payments please contact us via email on info@drsahilvohra.com.au

Important Medicare Bulk Billing Update

From 1 July 2026, Medicare has changed the way patients consent to bulk billing. Patients are now required to provide a written or electronic signature to assign their Medicare benefit to the clinic. This consent can be completed before or after the appointment, but it must be obtained before the Medicare claim can be finalised.

If you receive a consent request from our clinic, please complete it as soon as possible.

If we do not receive your signed consent within 7 days of your appointment, we will be unable to process your consultation as a bulk-billed service. In that situation, you will be issued an invoice for the full consultation fee and will need to claim the Medicare rebate yourself through Medicare.

Thank you for your prompt attention and for helping us comply with the new Medicare requirements.

Patient Data Storage

Your personal and medical information is securely stored using Gentu®, a cloud-based medical software platform used by healthcare providers across Australia. Data is protected using secure Australian cloud infrastructure, encryption, automated backups, and industry-standard security measures to help ensure confidentiality and privacy of patient records.

Name

First NameLast Name

Signature

New Patient Registration Form

BGB Better Growing Bodies Healthcare Clinic