Review Patient Registration

Patients First Name*

Please enter patients first name
Patients Last Name*

Please enter patients first name
Date of Birth*

Please enter Date of Birth
Parent(s) Names

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Best Contact Email Address*

Please enter email address
Telephone*

Please enter phone number
Please upload your GP Referral

Please attach your GP referral
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.*

Yes, I give my consent.
Please tick the box. You are not able to complete this form without giving consent.
If you (the patient) agree to the assignment of the Medicare benefit directly to the provider (bulk- bill), please tick and sign below*

Yes, I agree to the assignment of the Medicare benefit directly to the provider and this privacy note.
Please tick the box.
Patients name*

Enter Patient / Guardian name
*

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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.