Registration

Your details

Title

Surname

Given name/s

Date of birth

Gender

Mobile phone

Address

Emergency contact / next of kin

Name of contact

Phone number of contact

Relationship to you

Referring doctor

Referring doctor’s name

Referring doctor’s practice name and suburb

Regular GP’s name

If different from referring doctor.

Regular GP’s practice name and suburb

If different from referring doctor.

Medicare details

Medicare card number

Medicare reference number

Number next to name

Expiry

Private health insurance

Do you have private health insurance?

Yes

Health fund name

Membership number

Type of cover

Department of Veterans Affairs

Do you have a DVA card?

Yes

Card type white/gold?

White

Gold

Card number

Workers Compensation & CTP

Does this relate to a workers compensation or CTP claim?

Yes

Name of insurer

Claim number

Date of injury

Has your insurer provided written approval for this appointment?

Recent imaging

Have you had a recent scan (e.g. CT or MRI) that relates to your condition?

Yes

What was it?

Where was it completed?

The company/facility name, e.g. Hunter Imaging Group, Clarity Imaging, John Hunter Hospital

Fees

This is a private practice and fees apply. As of July 2025, an initial consultation is $350 with a Medicare rebate of $130.40. Follow-up consultations are $200 with a rebate of $86.15.

We do not charge fees for cancelled appointments, but we would appreciate as much notice as you can give should you need to cancel.

Privacy information

We act in accordance with the Privacy Act 1988 and the Australian Privacy Principles. Our practice software (Xestro) has ISO 27001 certification, providing the highest standard of information security.

In order to assess, diagnose and treat your condition, we may need to share your information with other healthcare providers (e.g. make referrals, hospital bookings), or seek health information about you (e.g. imaging, other tests, correspondence from doctors). Please feel free to discuss this further during your appointment.

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Patient Registration