Peninsula Paediatrics and Allergy - New Patient Registration

Required fields *

APPLICANT'S INFORMATION

Applicant's Name

Applicant's Email Address

CHILD'S INFORMATION

Full Name:

Date of Birth

Day

Month

Year

Gender

Male Female Other Prefer not to say

Address:

Language spoken at home:

Child's Medicare Number:

Reference Number:

Expiry Date:

Are Vaccinations up to date?

Yes No

Referring Doctor's Details:

Upload Referrals here: (jpg, gif, pdf, doc, docx files accepted - max 10MB file size)

Usual GP's Details: (if different from above)

PARENT/GUARDIAN INFORMATION

Parent/Guardian 1

Full Name:

Relationship to Child:

Telephone:

Email Address:

Address: (if different from above)

Parent/Guardian 2

Full Name:

Relationship to Child:

Telephone:

Email Address:

Address: (if different from above)

ADDITIONAL NOTES OR SPECIAL INSTRUCTIONS

Please notify Peninsula Paediatrics and Allergy of any Family Court orders, Intervention Orders, Legal Guardians and Medical Powers of Attorney (if different from above). Please upload copies of the relevant documents

Upload Documents here: (jpg, gif, pdf, doc, docx files accepted - max 2MB file size)

PERSON RESPONSIBLE FOR PAYING ACCOUNT

Please note - accounts must be paid on the day of consultation

Name:

Address and email: (if different from above)

Telephone: (if different from above)

Your Medicare Number:

Reference Number:

Expiry Date:

Your date of Birth

Day

Month

Year

(Your Medicare number and Date of Birth are required by Medicare for processing your Medicare Rebate)

CONSENT AND AUTHORIZATION

Treatment Consent:

I consent to the assessment and treatment of my child by Associate Professor Michael Nowotny

Name

Relationship to Patient

Day

Month

Year

PRIVACY CONSENT

Privacy Consent:

I consent to:

Associate Professor Nowotny sharing my child’s health and personal information:
(a) With the referring doctor and other clinicians outside this medical practice involved in my child’s care.
(b) For the purpose of arranging investigations relating to my child’s health, prescriptions and other treatment related activities, and for the reasons outlined in the Peninsula Paediatrics and Allergy Privacy Policy.
The release of my child’s health and personal information to the extent necessary for administration and billing purposes, Medicare rebates and compliance with Medicare and Health Insurance Commission requirements.

Name of Parent/Guardian:

Peninsula Paediatrics and Allergy - New Patient Registration

Infant, Toddler & Children allergy specialists

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