Patient Registration Form

All information provided on this page complies with our privacy and confidentiality policies and will be used solely by Kingsley Medical to assist in the provision of your health care. This information will not be used for marketing purposes.

 

Kingsley Medical is a private billing clinic. Before attending, please take the time to understand our fees and billing schedule. Click here for more information.

 

Please complete the following online form before attending our clinic, or click here to download and print each form instead. Bring your completed forms to your first consultation and arrive 5 minutes before your scheduled appointment time.

 

Your details

Title *

Family name *

Given name *

Middle name

Preferred name

Person responsible for payment of this account: (name & address) or "As above" *

Date of birth *

Marital status

Gender *

Ethnicity

Are you an Aboriginal or Torres Strait Islander *?

 

Contact details

Street address *

Suburb *

Post code *

Postal address (if different from above)

Mobile phone

Do you agree to be sent SMS appointment reminders? *

Note: All missed consultations or late cancellations (less that two [2] hours) will incur a $50 fee.
Home phone

Work phone

Email address *

Occupation

How did you hear about us? *

Other

 

Medicare / Pension / Health insurance details

Medicare number *

IRN (the number to the left of your name on your Medicare card) *

Expiry *

Pension/Healthcare card number

Expiry

Private health insurance provider

Aged pension *

Please note that discounted fees apply to aged pensioners and children under 16 for appointments after 8am on weekdays.
Full fees apply to ALL patients before 8am and on weekends.

DVA number

Card type

Conditions for use of DVA card (excludes Gold card)

W/Comp / MVA:
Insurance co

Date of injury

Claim no

Emergency Contact/ Next of Kin:
Name *

Phone *

Relationship *

 

Medical history

Weight (kg) *

Height (cm) *

Allergies/intolerances
Do you have any allergies?

 
List all medications, foods or products that you have had allergic or adverse reactions to
and list the type of reaction you've had to each, e.g. rash, nausea, diarrhoea etc.

Current smoking history
Do you smoke? *

 
Year started

Cigarettes/cigars per day

Year finished (or leave blank if still a current smoker)

Current alcohol consumption
Do you drink alcohol? *

 
Days per week (alcohol consumed)

Standard drinks per day

Past alcohol consumption

Family history
Is your mother alive? *

 
Cause of death (if known)

Is your father alive? *

 
Cause of death (if known)

Please itemise any Chronic Medical Conditions of family members. This includes: high blood pressure, high cholesterol, cancer, stroke, heart attack, Parkinsons, multiple sclerosis, diabetes, skin cancer.
Mother

Father

Brothers

Sisters

 

Your declaration

Please read the following and submit below:

Fees, payment terms and referrals

 

I understand that discounted fees apply to AGED pensioners and children under 16 years of age. Full fees apply to all other patients. Please do not ask to be ‘bulk billed’.

 

I am aware that I will be responsible for payment of any fees that I incur due to missed appointments or late cancellations. I understand that I will incur a fee of $50 for any appointment that is missed or cancelled with less than 2 hours notification. This fee is payable regardless of whether I am a veteran (DVA), workers compensation, motor vehicle accident (MVA) or private patient.

 

I understand that all payments will be made on the day of consultation. In cases of delayed or disputed liability (Workers compensation of Motor Vehicle Accident) I will be asked to fully settle all accounts greater than 4 weeks old.

 

I understand that if payment of my account is disputed or denied by a third-party insurer, I am liable to settle my account within 4 weeks of notification. I understand that if my account is not settled within 4 weeks that I will incur a $75 administration fee. All accounts outstanding beyond 4 weeks will be forwarded to a debt collection agency where an additional 30% of the total outstanding fee will be added to the account. I understand that I am responsible for all costs associated with the collection of unpaid invoices.

 

Kingsley Medical, Kingsley Physiotherapy and Kingsley Studio are jointly owned and operated and cross referral of patients between these businesses may occur without prejudice. You are not obliged to utilise the professional referral recommendations of our staff.

 

I understand that all services including surgical procedures, injections, biopsies, cryotherapy, taping and wound dressing will incur a fee in addition to the service fee. An outline of our fees can be provided to you upon request and can be found on our website. Click here for more information about our fees and services.

 

Australian Privacy Principles

I have read the Australian Privacy Principles - Patient Consent Form and understand the reasons why my information must be collected, and the purposes for which my information may be used or disclosed. I understand that if my information is to be used for any purpose other than that set out above, my further consent will be obtained.

 

I give permission for my personal information to be collected, used and disclosed as described above (including contact via SMS to my mobile phone number). I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.

 

If you are not the patient

Your name

Your relationship to patient (e.g. Mother, Father, guardian)

 

By submitting this form, you declare that you have read, understand and agree to the terms and conditions above.