Patient Registration

Please complete the below before your visit

Patient Registration

Your Details

Appointment Details

Who is the appointment for?
Is the appointment for a child under 14 years of age?

Please complete the section ‘Your Medicare Details‘ below. This information is required for claiming purposes.

Child’s Details

Are there any past/current Court orders in place for this child?

Child’s Medicare Details

Your Medicare Details

Concession, Pension, Veterans Affairs Details

Do you have a Concession Card (eg. Aged Pension/Disability)
Do you have a Veterans Affairs Card?

Next Of Kin/ Emergency Contact Details

Referring Doctor

Is this your Family Doctor / GP?
Are there any other specialists you would like us to send our correspondence to?

Medication

Upload Documents (e.g. GP referrals)

Maximum file size: 15MB

pdf, jpeg, png, gif files accepted. Max file size 15mb.

Communication Consent & Information Preferences

Our practice uses a reminder system to help you maintain your health. The practice sends you reminders by post, email, telephone, or SMS for appointments, order collections, immunotherapy treatments.

Allergy Immunology Associates may use a note taking tool called HEIDI to accurately capture the details of discussions and outcomes. Information on HEIDI is displayed in the waiting room and our staff are happy to answer any questions you may have. By signing this form, you are agreeing to allow your clinician to use HEIDI during your consultation.

I hereby authorise Allergy Immunology Associates clinicians to record notes regarding my medical condition and to supply only necessary documents, reports or certificates to Doctors, Solicitors, and Insurers, who are taking part in management of my medical condition/s as they are formally requested. I confirm the above details are correct and undertake to pay all fees owing to Allergy Immunology Associates.

I acknowledge the statement above and consent to being contacted by the practice for reminders via SMS, post, or email.

Communication & Information Selections
Communication & Information Selections (Optional)

How did you hear about us? *