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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 Detials

  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
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  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. Next of Kin / Emergency Contact

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


  28. Invalid Input
  29. 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.
  30. 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.