New Patient Registration

Patient Details

Patients First Name*

Please enter patients first name

Date of Birth*

Please enter Date of Birth

Parent(s) Names

Invalid Input

Patients Last Name*

Please enter patients first name

Occupation

Invalid Input

Contact Details

Best Contact Email Address*

Please enter email address

Address*

Please enter your address

State*

Please select state

Telephone*

Please enter phone number

Suburb*

Please enter your suburb

Post code*

Please enter post code

Mobile Phone

Please enter your mobile number

Health Fund

Private Health Fund*

Please enter fund name or Nil

Private Health Membership Number*

Please enter fund name or Nil

Other Details

Medicare Number

Veterans Affairs Number

Please upload your GP Referral

Please attach your GP referral

Pension Number

TAC or Workcover Number

Next of Kin / Emergency Contact

Name*

Please answer

Contact Number*

Please answer

Relationship*

Please answer

Account Details

Person responsible for account*

Please make a selection

Date of Birth

Invalid Input

Expiry

Invalid Input

Full Name

Invalid Input

Medicare Details

Invalid Input

Consent

If you DO NOT CONSENT to a message being left for you on the telephone numbers you have provided us, PLEASE TICK THIS BOX Invalid Input

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 our privacy policy. Please tick the box.

Patients name*

Enter Patient / Guardian name

Invalid Input

New Patient Registration

Patient Details

Contact Details

Health Fund

Other Details

Next of Kin / Emergency Contact

Account Details

Consent

Make an appointment today