Registration Form

    Medicare Number :
    Medicare Ref No. :  

    Concession Card(if applicable) :  
    Concession Type :  

    If you don't have Medicare
    Private Insurance Company :  
    Private Insurance Type :  
    Private Insurance Policy Number :  

    Title:       Sex :  
    First Name :   Surname :  

    Birth Date :  

    Residential Address(with unit number if applicable):  
    Suburb :  
    Post Code :  
    Mobile Phone :  
    Home Phone :  
    Email :  

    CULTURAL BACKGROUND
    Do you identify as being Aboriginal :  
    Do you identify as being Torres Strait Islander :  
    Country of Birth :  
    Ethnicity :  
    Language Spoken :  
    Preferred Language Spoken :  

    Details of Your NEXT OF KIN
    Name :  
    Relationship to Patient :  
    Phone Number :  

    Details of Your EMERGENCY CONTACT (if different)
    Name :  
    Relationship to Patient :  
    Phone Number :  

    (Please read this consent and agreement carefully prior to sign):

    1) I understand that collecting my personal information and medical history is required to ensure high quality healthcare, accurate Medicare/Insurance billing and referral to other specialists or hospitals.
    2) I shall inform AIM Health if there are any changes to my contact details, such as address and phone / mobile number. If I am unable to be contacted, I understand that I am responsible for any associated consequences.
    3) I consent for AIM Health to send me reminders via SMS, phone call, letter or email.
    4) I consent for AIM Health to submit data to diseases registers to assist with preventative health management (e.g. cervical, breast and bowel screening, etc.) and share de-identified information for quality improvement and clinical audit activities purposes.
    5) I agree that I need to make an appointment to discuss my results, or obtain referrals, prescription, medical certificate, MHCP, EPC, etc.
    6) I understand that AIM Health requires at least 24hrs notice to cancel or reschedule an appointment. Failure to do so may result in a cancellation fee of $40, which needs to be paid within 7 days.
    7) I am aware that there will be an administration fee to transfer/obtain my medical records, which needs to be paid upfront, as per the Australian Health Record Regulation.
    8) I need to make a longer appointment if I have more than one issue or complex health conditions: e.g. TAC or Workcover (not covered by Medicare), referral for mental health care plan, to allied health providers, EPC referral –as per Medicare / insurance requirements under GP Management, etc.
    9) I agree to the assignment of the Medicare benefit directly to the provider unless other arrangement on the day.

    Please sign here

    Signed on :