Patient Registration Form

To ensure we provide you with the best possible care, we require some essential information. Please accurately and completely fill out the registration form below. Should you have any questions, do not hesitate to contact our admin team.

Personal Details

Title

Name

First Name

Last Name

Preferred Name

Maiden Name

Date of Birth

Occupation

Contact Details

Mobile Number

(###)

###

####

Email Address

Residential Address

Postal Address

You can leave it empty if it is the same as the residential address

Next of Kin / Emergency Contact Details

Full Name

Mobile Number

(###)

###

####

Relationship

Occupation

Referring Doctor Details

Referring GP Name

Name of Regular GP

Medicare / Private Health Insurance Details

Medicare Card Number

Medicare Reference Number

Do you have private health insurance with gynaecology cover?

Fund Name

Membership Number

Berth collects information from you for the primary purpose of providing quality health care. We require your personal details and medical history (including information from other treating medical practitioners, the Australian Immunisation Register and the Cervical Screening Register) so that we may properly assess, diagnose and treat illnesses and be pro-active in your health care. We may use the information you provide in the following ways: - Administrative Purposes: Running our medical practice efficiently. - Billing: Ensuring compliance with Medicare and Health Insurance Commission requirements. - Sharing Your Information: We may disclose your information to SJOG Hospital, other treating medical practitioners, or for medical tests and referrals. We only use your information for these purposes unless discussed with you first.

I have read and agree to the Privacy Policy outlined above

YES

I confirm that I have reviewed Berth's informed financial consent and understand that I must pay for my consultations at the time of my appointment.

YES

I consent to being contacted with reminders to help me maintain my health

Berth also uses a reminder system to provide you with comprehensive health care. We may send reminders by post, email, telephone or SMS for appointments, procedures and other overdue health reviews.

YES

Signed By

Please type your name in full

Date Signed

Our experienced team possesses the knowledge and compassion to care for you and address any of your gynaecological concerns. We invite you to reach out with any questions you may have – we're here to help!