Registration

Your details

Title

Surname

Given name/s

Preferred name

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

Medical History

Recent medical/surgical history

Please list any relevant or recent medical conditions or surgical procedures.

Current medications

Please enter your current medications including doses.

Fees

This is a private practice and fees apply to consultations and surgery. If you require bulk-billed care, please direct your referral to John Hunter Hospital.

As of June 2026, the fee for an initial consultation is $350, with a Medicare rebate of $133.80. Follow-up consultations are $200, with a Medicare rebate of $88.40.

Forty-five minutes are allocated for new consultations. I do not have trainees or fellows consulting on my behalf. All consultations, medical correspondence and clinical decision-making are undertaken personally by me.

Cancellations

There is no fee for cancelling an appointment. However, I would appreciate as much notice as possible if you are unable to attend. Patients who repeatedly cancel appointments at short notice, or who do not give any notice that they will not be attending may be asked to seek care elsewhere.

Privacy

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). Further information is available in our Privacy Policy. Please feel free to discuss this further during your appointment.

Acknowledgement

I have read and acknowledge the above, and have provided true, complete and accurate information.

If you are human, leave this field blank.

Patient Registration