Registration Form LZ

Title/Salutation (required)

—Please choose an option—MsMrsMissMrMasterMxDrProfRevLadySirCaptLt

Your Name (required)

Date of Birth (required)

Your Address (required)

Your Postal Address if different (required)

Your Email (required)

Mobile phone number (required)

Home phone number (mobile preferred)

Occupation

Referring Doctor (required)

Referring Doctor Address

Name of GP (if different from referring doctor)

Address or Suburb of GP (if different from referring doctor)

Who is responsible for account payment?

Medicare Number (required)

Medicare Ref Number (required)

Medicare Exp Date MM/YY (required)

Are your bank details registered with Medicare?

—Please choose an option—YesNoUnsure

Is this referral related to a WorkCover or TAC claim? (required)

—Please choose an option—NoYes

If "Yes" what is the TAC/WorkCover Claim Number?

Private Health Insurer

Private Health Number

Are you on a Full Pension?

NoYes

Are you on a Part Pension?

NoYes

Pension Number

Health Care Card Number

I have read and accept the fee statement outlined on this page (required)

—Please choose an option—NoYes

I have read and accept the privacy policy (required)

—Please choose an option—NoYes

I am happy for medical correspondence regarding my care to be transmitted via email (required)

—Please choose an option—YesNo

I will notify staff if correspondence regarding my personal and medical information should not be sent via email (required)

—Please choose an option—YesNo

Please leave this field empty.