Patient Registration & Consent Form

Name

This field is for validation purposes and should be left unchanged.

Title*

First Name*

Surname (as per Medicare card)*

Date of Birth*

How did you hear about us?*

Other

Address*

Street Address City State Postcode

Telephone - Mobile*

Telephone - Home

Telephone - Work

Email*

By providing your email you are agreeing to receive correspondence regarding your medical care.

Occupation

Medicare and Health Fund

Medicare No.*

Ref No. (# next to your name)*

Expiry Date*

Insured / Uninsured

Please Select if Insured / Uninsured*

If INSURED, it is important you complete the Private Health Fund details below.

Private Health Fund

Membership No.

Date joined

Level of Cover

Pregnancy / Fertility services included?

Level of cover

Waiting period served

Yes
No

If uninsured

Health Care Card/Pension No.

Dept of Veterans Affairs No.

Have you had any recent scans or pathology done in relation to the purpose of your appointment today?

Recent Pathology?

Yes
No

Recent Scans?

Yes
No

Next of Kin Details

Next of Kin Name

Next of Kin Contact Number

Next of Kin Relationship

I ACKNOWLEDGE there may be additional fees for anesthetic, radiology, pathology services which are separate from Dr Eva Kretowicz, and these services will be billed separately by the service provider/s concerned. I consent to you arranging these services as part of my care. Please call SNP 3377 8748 or QML 3121 4444 to check your pathology fees.

Patient Consent

Dr Eva Kretowicz requires your consent to collect personal information about you.

Please read this information carefully and sign where indicated below.

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and full medical history so that we properly assess, diagnose, treat, and be proactive in your health care needs. In addition we will use information you provide in the following ways:

Administrative purposes in running our medical practice.
Billing purposes, including compliance with medical and health insurance commission requirements.
Sharing of information with other health practitioners involved in your care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and the reports/results returned to us following the referral.
Notification to Queensland Health of certain diseases as required by Law.

Please confirm the following:

Patient Registration & Consent Form

New patients must complete the form below prior to your appointment.

Medicare and Health Fund

Insured / Uninsured

If uninsured

Have you had any recent scans or pathology done in relation to the purpose of your appointment today?

Next of Kin Details

Patient Consent

Dr Eva Kretowicz

Book an Appointment.

Spring Hill

North West Private Hospital