Dr Vera Kinzel - Patient Registration Form

Patient Registration Form
Title:
First Name:
Surname:
Date of Birth:

DayMonthYear
Mobile No.:
Home No.:
Street Address:
No. / Street
Suburb:
State:
Post Code:
Email Address:
Occupation:
HEALTH FUND AND INSURANCE DETAILS:
Medicare Card No.:
Medicare ID No: (Left of Name)
For claiming purposes, if the patient is under 13, parent's details are required:
Parent's Name:
DOB:

DayMonthYear
Medicare No:
Medicare ID No: (Left of Name)
Private Health Fund:
Membership Number:
Veteran's Affairs DVA No:
Card Colour:

DECLARATION: ALL PATIENTS TO SIGN PLEASE:

I give permission for correspondence to be sent to my referring Doctor, GP and Insurance Company where appropriate. I undertake to pay all fees owing to Dr Kinzel, including in the event that liability is denied or any outstanding accounts that my insurer has not paid in full. I also understand that any outstanding monies requiring debt recovery will incur Debt Recovery fees, and I will also be responsible for any legal costs incurred.
Signature
Date

DayMonthYear
Are you making a claim for compensation?
Insurance Company:
Date of Injury:
(MM/YY)
Claim Number:
Case Manager's Name:
Case Manager's Phone No.:
Email Address:

Patient Registration Form