Patient Registration Form – South Eastern Gastroenterology (SEG)

Patient's Name *

First

Last

Date Of Birth *//

Mobile Number *

Home Phone Number

Email Address

Acknowledgement - Email Communication *

By providing my email address, I give permission to communicate with me via this email address and any other address that I may provide in the future, and I am aware that this is not a secure form of communication.

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Medicare Card Number (if you do not have one, please enter N/A) *

Reference Number *

Private Health Fund

Membership Number

Pension Card Number (CRN)

Aged or Concession Card ONLY - Health Care Card is not accepted

Emergency Contact Information

Name *

First

Last

Relationship *

Contact Number *

Doctor's Information

Referring Doctor *

First

Last

Family Doctor (GP) *

First

Last

Please upload your referral below.

Referral

A valid referral must be submitted to proceed with your consultation or procedure with our specialists. Please contact our office on 02 9398 0200 if you have any questions. If you are having problems uploading your referral, please email it to admin@segsydney.com.au.

If you do not have a referral ready to submit, please tick an option below.

I will bring the referral on the day of my appointment
My GP will fax my referral to the practice.

Patient's who are completing this for procedure booking purposes MUST submit a referral prior to booking any procedures.

Acknowledgement - Medical Record *

I acknowledge that as a patient of SEG Specialist Services Pty Ltd, a medical record containing personal information will be maintained throughout my treatment. During the period of assessment and ongoing management, information of relevance is recorded in clinical notes. These records will be stored securely and may be kept for up to seven years following your last consultation. If necessary, for the continuity of your medical care, this information may be shared with other health practitioners involved in your treatment. In certain circumstances there may be a legal obligation to disclose clinical information.

Acknowledgement *

Our team is regularly active in clinical research projects, auditing and quality improvement initiatives which requires analysis and review of patient data. These projects include clinical research which may be submitted for publication to medical journals, as well as quality improvement activities to ensure processes and patient outcomes are continually improving. In order to conduct these projects, our staff, contractors, or a representative from an external agency who has been authorised by us, may require access to your health information, may need to discuss your health information with other health professionals and/or permission to contact you for additional follow-up. Any activity outline above, including research which is published or made public, will be de-identified such that your personal information will not be released in any way. By ticking this box, you consent to the access and use of your health information for clinical research, review and/or quality improvement activities.

Acknowledgement - Online Claiming *

Where applicable, I hereby give permission for SEG Specialist Services Pty Ltd to use Medicare Online Claiming and/or online electronic account transmission on my behalf when required, and I assign my right to Medicare benefits to the Practitioner who rendered the service/s.

Acknowledgement - Out of Pocket Costs *

I acknowledge that there may be out-of-pocket costs for services provided, and that it is my responsibility to confirm with Medicare and/or my insurer (if any) as to my eligibility and the amount of any reimbursement.