Online Intake Form Psychiatrist

Cygnet Psychiatry Patient Registration Form

Intake Form for Consultant Psychiatry Consultations
Title
Patient Name*

First NameLast Name
E-mail
Birth Date*

DayMonthYear
Contact Telephone*
Address

Street Address

Suburb

CityState / Province

Postal / Zip Code
Next of Kin - Full Name
Name for someone to contact in emergency
Relationship to you
eg, Mother, Parent, sibling, other
Next of Kin Contact Telephone Number

Referrer/GP Name (Please note, a referral is required for Psychiatry). If the patient does not have a referral ready to send, ask them politely to do so and do not proceed with this form until you have a scanned electronic copy to book in as a requirement)
Referrer Address/GP Practice
Brief reason for seeing a Psychiatrist (the more information reception can obtain the better - it gives Psychiatry more insight into appropriateness of the referral)?*
Referral For:*
Preferred Location*
Upload Referral from GP*

Browse Files
as a pdf or jpg files using a camera and emailing it to referrals@cygnetclinic.com.au. This referral will not be approved without a valid referral Cancelof
Covered Under*
Additional Information
If there is any additional information you would like to include in your referral request, please let us know here.
Preferred Cygnet Clinic Psychiatrist
Patient Reminder Preference?

SMSEmailBothNo I do not want reminders

Medicare Direct Online Claiming
Optional information for Medicare and Bank Details for Rebates
Medicare Number
Individual Reference Number (IRN)
(the number next to your name on your medicare card)
Expiry MMYY
For example Valid To 09/2020 would be 0920

Bank Account Details for Medicare Rebate Deposit

So your rebate can be quickly deposited back into your account. If you have already registered your bank account details with Medicare, then this section is optional (although the rebate will be processed faster).
Account Name
Account Number
BSB
This section is optional - if the patient has their bank account already registered with Medicare (most are) then this can be skipped.

Cygnet Psychiatry Patient Registration Form