Patient Registration Form

Acceptance/Cancellation/Deferment

Hospital Contact reference number/Medical Record Number*:

I would like to accept the outpatient appointment offered by the hospital:

Yes No

Please call the Appointment Centre on telephone: 9767 5333 or
email: SLHD-ConcordAppointmentCentreACBU@health.nsw.gov.au

Deferment of Admission:

I request that my admission be deferred. My reason for requesting deferral is*:

I will be available after*:

Agree*:

I understand that there is a maximum timeframe that a patient can elect to defer their surgery for personal reasons. If you defer your admission, on two occasions for non-medical reasons, your name will be removed from the waiting list.

Cancellation

Personal details required:

Surname*:

Given Name/s*:

Address*:

Email*:

Date of birth*:

Cancellation of Admission:

I request that my admission be cancelled. My reason is*:

Other reason for requesting cancellation*:

Agree*:

Agree

I'm not a robot

Personal Details

Title*:

Surname*:

Given Name*:

Middle Name/s:

Gender*:

Male Female

Date of birth*:

Age:

Do you have a Medicare card?

Yes No

Mailing Address

If same as Residential Address

Mailing Address*:

Temporary Sydney Address for visitors (Overseas or Country Patients)

General Practitioner/Local Doctor

Is a General Practitioner/Local Doctor available for this Patient?*

Yes No

Financial Details

Pension Type:

Other Pension Type:

Centrelink Number/Pension No:

Expiry Date:

NDIS eligibility

Yes No

Participant Number:

Workers Compensation/Third Party Liability/Motor Vehicle Accident Claims

Are you entitled to Third Party Claim?

Yes No

Are you Entitled to Workers comp (approval required)?

Yes No

Did the accident occur in the course of your employment?

Yes No

Please specify

Employer Name:

Employer Address:

Post Code: or enter:

Contact Name:

Claim Number:

Insurer Name:

Date of Injury:

Solicitor's Name:

Solicitor's Telephone:

Solicitor's Address:

Is this visit related to a Motor Vehicle Accident?

Yes No

Existing Claim Number:

Overseas Visitor

Are you an Overseas Visitor?*

Yes No

Please specify (Required *)

Are you a member of Health Fund/Travel insurance?*

Yes No

Name of Fund*:

Membership number*:

Table of Cover*:

Date Joined Fund*:

Date joined current table of cover*:

Excess amount*:

Passport number*:

Visa number*:

Date of Visa Entry*:

Type of Visa*:

Reciprocal rights:

Overseas Address:

Town/City:

Postcode:

Country:

Contact 1 (This is the person that you would like to be contacted in an Emergency)

Relationship to patient*:

Surname*:

Given Name*:

Gender:

Male Female

Date of birth:

Address:

Phone number at home*:

Mobile:

Phone number at work:

Contact 2. (This is the person that you would like to be contacted when Contact 1 is unavailable)

Same as Person to contact?*

Yes No

Carer Details

Do you have a carer? *

Yes No

Please specify (Required *)

Your carer *

Same as person to Contact 1 Same as person to Contact 2 Different

Do you provide care for another person *

Yes No

General Comments

I'm not a robot

Healthcare Rights

Acceptance/Cancellation/Deferment

Deferment of Admission:

Cancellation

Personal Details

Please specify (Required *)

Residential Address

Mailing Address

General Practitioner/Local Doctor

Please specify (Required *)

Financial Details

Workers Compensation/Third Party Liability/Motor Vehicle Accident Claims

Please specify

Private Health Fund Information

Please specify (Required *)

Please specify (Required *)

Please specify (Required *)

Please specify

Veterans' Affairs

Please specify (Required *)

Please specify

Overseas Visitor

Please specify (Required *)

Contact 1 (This is the person that you would like to be contacted in an Emergency)

Contact 2. (This is the person that you would like to be contacted when Contact 1 is unavailable)

Please specify (Required *)

Carer Details

Please specify (Required *)

Please specify (Required *)

General Comments

Patient Registration Form
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