Patient Registration Form

Important: Please complete this form & return to CDD at least FOUR WORKING DAYS PRIOR to your procedure.

*Required field.

Procedure*
Proceduralist
Procedure Date*

Personal Details

Surname*
Given Name/s*
Address
Post code
Date of birth*   Sex
Marital Status
Occupation
Home phone*   Work phone
Mobile phone
Email*
Religion
Country of birth
Language spoken
Medicare number   Expiry
No. next to given name   Reciprocal card Yes No

Next of Kin

Name*
Contact details*
Relationship to patient*

Financial Details*

Private Health Fund (fill in Section 1)
Pension / Health Care Card (fill in Section 2)
Veterans Affairs Card (fill in Section 3)
None of the above (read Section 4)
No Medicare / Overseas patient (read Section 5)

Section 1 - Health Fund Details

Name of Health Fund
Membership No.
Please note: CDD will check your level of health fund cover prior to your procedure. However, it remains the patient's responsibility to pay any out-of-pocket expense or health fund excess on the day of the procedure.

Section 2 - Pension / Health Care Card

Pension / HCC Number
Please note: As a pension card / HCC holder, all doctors fees will be bulk billed. However, there will be expenses not covered by Medicare for theatre and accommodation. You will be advised of the approximate cost prior to your procedure - this is payable on the of your procedure.

Section 3 - Veterans Affairs Card

Card Number
White Card  Gold Card

Section 4 - Uninsured Patients

CDD is a PRIVATE Day Hospital. You will need to pay expenses not covered by Medicare for doctors fees, theatre and accommodation. You will be quoted an approximate cost for your procedure. This is payable on the day of your procedure.

Section 5 - No Medicare / Overseas Patients

You will need to pay the full cost for Doctors fees, theatre and accommodation. You will be quoted an approximate cost prior to your procedure - all fees are payable on the day of the procedure.

• I agree and accept responsibility for the charges levied by the Centre for Digestive Diseases for theatre, accommodation and medical consultations. I acknowledge that there may be further charges for disposable items used during my procedure which cannot be foreseen.



• I agree to the Centre for digestive Diseases accessing all relevant information about my medical condition or history to other health care providers. I understand to provide the highest medical care, my clinical records may be accessed and reviewed by staff of this practice and, in some circumstances other health care providers.

I agree.*