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New Patient Registration

All new patients need to register prior to seeing a specialist. This can take place upon arriving at the consultation or via the online form below. Filling in forms in advance will make your appointment experience smoother. 

All information you enter will be treated confidentially according to our Privacy Policy. Read it here (pdf).

  1. Patient Details

  2. Patients First Name*
    Please enter patients first name
  3. Patients Last Name*
    Please enter patients first name
  4. Date of Birth*
    Please enter Date of Birth
  5. Parent(s) Names
    Invalid Input
  6. Occupation
    Invalid Input
  7. Contact Details

  8. Best Contact Email Address*
    Please enter email address
  9. Address*
    Please enter your address
  10. Suburb*
    Please enter your suburb
  11. State*
    Please select state
  12. Post code*
    Please enter post code
  13. Telephone*
    Please enter phone number
  14. Mobile Phone
    Please enter your mobile number
  15. Health Fund

  16. Private Health Fund*
    Please enter fund name or Nil
  17. Private Health Membership Number*
    Please enter fund name or Nil
  18. Other Details

  19. Medicare Number
  20. Pension Number
  21. Veterans Affairs Number
  22. TAC or Workcover Number
  23. Please upload your GP Referral
    Please attach your GP referral
  24. Next of Kin / Emergency Contact

  25. Name*
    Please answer
  26. Relationship*
    Please answer
  27. Contact Number*
    Please answer
  28. Account Details


  29. Invalid Input

  30. I consent to the handling of my information by this practice for the purposes set out above, subject to any limitation on access or disclosure that I notify this practice of. I acknowledge that I am personally liable for fees resulting from consultations with the Doctors at ENTV and that Staff of ENTV are not able to provide quotations for other medical companies involved in my care.*
    Please tick the box. You are not able to complete this form without giving consent.

  31. If you (the patient) agree to the assignment of the Medicare benefit directly to the provider (bulk- bill), please tick and sign below*
    Please tick the box.
  32. Patients name*
    Enter Patient / Guardian name

  33. *
    Invalid Input
 

The Fine Print:

In accordance with standard business practice, payment is requested at the time of consultation.             

For eligible patients, a portion of your account will be claimable from Medicare.

There may be additional charges associated with your consultation for various treatments recommended by your specialist. These may include tests such as radiology, pathology, audiology, speech pathology, anaesthetics and hospital expenses. Some of these may incur out of pocket costs. Information regarding fees and charges for these additional services can be obtained from the provider you are referred to. ENTV CAN NOT PROVIDE QUOTES FOR ANY OF THESE ADDITIONAL SERVICES.

Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services. This information is required to process your application or claim. Your information may be used by the department or given to other parties where you have agreed to that, or where it is required or authorised by law (including for the purpose of research or conducting investigations). You can get more information about the way in which the department will manage your personal information, including its privacy policy.