Patient Registration Patient RegistrationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Address Street Address Suburb Postcode D.O.BEmail* Home PhoneMobile PhoneWork PhonePreferred phone: Home Work MobileOccupationNext of Kin Details (family member or friend)Name First Last Relationship to youContact numberClaim detailsMedicare numberRef numberExpiryPrivate health insurance Yes NoFund NameFund NumberConcession CardsAged or disability pension numberExpiry dateDept veterans affairs card numberColour White GoldExpiry dateHealth care card numberExpiry dateREFERRAL SOURCEUsual GP name First Last Practice detailsHow did you hear about us? Referred by Doctor GP Specialist Website Google Yellow Pages White Pages Personal recommendation OtherPlease detail 'other':Would you like to opt out of the inclusion of your Yarra Gastroenterology health records into My Health Record? Yes NoFINANCIAL RESPONSIBILITYAll consultations and procedures are charged to the patient and are payable at the time of service. We can accept EFTPOS, Visa, Mastercard, cheque and cash. Necessary forms will be completed to help expedite insurance carrier payments, however you are responsible for all fees regardless of insurance coverage.For medical services rendered to myself regardless of my insurance benefits, if any, I understand that I am responsible for any amount not covered by my insurance.I have requested medical services from … Dr Edward Shelton Dr Dilip Ratnam… on behalf of myself and understand that by making this request I become fully financially responsible for any and all charges incurred in the course of the treatment authorised. I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of appropriate statement. A photocopy of this assignment is to be considered as valid as the original.SignatureDate MM slash DD slash YYYY HEALTH RECORDS COLLECTION STATEMENTYour doctor is collecting your health information for providing you with health services. Please read and sign to give approval for this information to be collected and stored.Your medical information will be used exclusively for providing health care in the following way:To gain a history, diagnose disease and provide treatment where necessary;Administrative purposes in running this Practice, which may also include confirmation of your appointment.Writing reports to your Doctor and other Doctors involved in the provision of healthcare and the storing of reports provided to this Practice by other Medical Specialists; andBilling and collection purposes, including but not limited to compliance with Private Health Fund, Medicare and Health Insurance Commission requirements. You may gain access to your health information by writing to us. If you do not consent to providing us with your health information, we may be unable to provide you with health services.I consent to my doctor (selected below) to collect my health information. Dr Edward Shelton Dr Dilip RatnamSignatureDate MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.