New Patient Registration Form

Personal Details

Title

Preferred Name

First Name *

Last Name *

Date of Birth *

Occupation

Street Address *

Suburb *

Postcode *

Mobile *

Email *If you do not have a valid email address, please type 'NA'

Emergency Contact Name *

Emergency Contact Mobile *

Medical Information

Do you identify as Aboriginal or Torres Strait Islander?

What is your country of birth?

Medicare card number (10 digits) *If you do not have Medicare, please type 'NA' to the relevant fields

Identifier (No. next to full name) *

Medicare Expiry Date *

DVA Card type (Gold or White)

DVA Card Number

DVA expiry

Parent/Guardian (Please skip to the next section if patient is over the age of 18)

Parent/Guardian - Full Name

Parent/Guardian - Medicare Card NumberWe require this information so that we can submit the claim with you as the claimant, as your child is under the age of 18.

Parent/Guardian - Date of BirthWe require this information so that we can submit the claim with you as the claimant, as your child is under the age of 18.

GP Details

Name of regular GP

Name of Medical Practice (where GP is located)

Address of Medical Practice

GP Referral*

Browse

*Please note, if this referral is addressed to a different clinic, you will need to have it readdress to Renaissance Dermatology. If your referral is from a GP, it lasts for 12 months and you will need to get a new referral after 12 months unless otherwise stated. If you are referred by your specialist, the referral lasts for 3 months and it is advisable that you obtain a referral from your GP for your next visit.

Patient Consent(s)

If clinically required, I consent for photographs to be taken during my consultation for the purposes of monitoring my condition *

YesNo

*Photos are taken, where appropriate, to assist in the monitoring, diagnosing or treatment of your condition. These clinical images are private and stored securely in our practice software. Your clinical photos are not shared with any third parties without your prior consent, nor will they be used in any publications, social media/marketing or educational materials. This is not compulsory and you can withdraw your consent at any time.

• I consent to my specialist(s) using Heidi Health, a program for note-taking, during my consultation *

YesNo

*This program, compliant with the Australian Privacy Principles, converts voice to text for your specialist and then saves it into your clinical record within the practice management software. It does not record any personal patient information such as name, date of birth, or address.

I understand that this appointment is for the purpose of addressing the issue specified on the referral letter. Any additional concerns will require a follow up appointment, and in some cases, a new referral *

Yes

I consent to receive SMS reminders, messages, and emails. *

YesNo

Yes, I understand that there is a fee (see below) for today’s consultation and any subsequent consultations. Any procedures or treatments will also incur additional fee(s) which will be explained to me prior to proceeding.

Initial Consultation/New Referral = $350 (Rebate $88.40)

Review Consultation = $250 (Rebate $44.45)

Extended Initial Consultation/New Referral (eg multiple issues OR Hair and Skin issues) = $500 (Rebate $88.40)

Extended Review Consultation (eg multiple issues OR Hair and Skin issues)= $400 (Rebate $44.45)

*Additional services may incur additional charges. Please discuss with the Doctor if you have any queries.

• I understand if I lost a prescription or need any additional prescriptions re-issued, this will incur a fee *

Yes

• I’d like to explore the laser and cosmetic services you offer for my skin concerns. *

YesNo

If yes, please choose one or more of the following:

Brightening / Dull SkinOily / Acne-prone skin Sun damage / PhotoagingDry / Sensitive / Reactive skin Redness / Rosacea-prone skinPigmentation / Melasma / Uneven Tone Anti-aging / Skin firming / Fine linesOther Areas (Neck and/or Hand Rejuvenation)

Privacy and Terms

We are committed to protecting the confidentiality of your persona information and health records. In submitting this form, you.

Acknowledge that we and our service providers, will collect your personal and health information to enable us to provide you with our health services and any related communications (for example, to manage your appointment bookings); and
Consent to our handling your personal information

Print Name *

Signed *

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Date *

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