Patient Information Form| Pensinsula Cardiology Group

Select a Doctor

Doctors:*

Personal Information

To assist in your first appointment please complete this form for our admin team.

Title:

Mr.

Ms.

Mrs.

Miss

Surname:*

Given Name:*

Date of Birth:

Gender:

Male

Female

Preferred Name:

If you do not wish to receive information including appointment reminders via SMS Please tick

I do not wish to receive reminders

Address:*

Phone (H)

Phone (W)

Phone (M)*

Email:*

Occupation:

Medicare No.*

Expiry Date:*

Ref

Health Fund

Membership No.

Dept. of Vet. Aff. No.

DVA Card Colour:

Clear

White

Gold

Orange

Who is responsible for your account?

Self

Others - Please provide details below

Surname:

Given Names:

Address:

Emergency Contact Information

Surname:*

Given Names:*

Phone: (H)

Phone: (W)

Phone: (M)*

Relationship to Patient*

Medical Practitioner Information

Referring Dr:*

Usual GP:

Referral Information: Referrals provided by a General Practitioner will last for a period of 12 months unless your Doctor has specified "ongoing" or "indefinite" referral. After 12 months it is essential for you to provide a new referral from your GP to meet Medicare requirements. If you have been referred by a Specialist Physician or through a Public Hospital your referral will only last for a period of three(3) months.

Medical Release

I provide consent for Peninsula Cardiology to obtain any relevant test results and correspondence relating to my medical history.

I provide consent for results and correspondence to be sent to my referring and usual doctors as well as other medical professionals involved in my care when requested.

I provide consent for messages to be left with immediate family members (eg, appointment confirmation).

I understand the Consultation Fees are due for payment on the day of Consultation (gap payments are not accepted). Accounts can be processed immediately in our rooms so that you receive your Medicare rebate directly into your nominated account normally within 24 hours.

Patient Signature*

Date*
DD slash MM slash YYYY

Patient Information Form

Select a Doctor

Personal Information

Emergency Contact Information

Medical Practitioner Information

Medical Release

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