New Patient Details

please complete details below to enable our staff to create a new patient record

Salutation

Mrs

Other

Name

First Name

Last Name

Date of Birth

DD / MM / YYYY

Address

Mobile Phone

Home Phone

Medicare Number

Medicare Card Number (4 digits + 5 digits + 1 digit) - large numbers at top of card refer image below

Medicare Reference

Medicare Ref Number (1 digit) - to the left of your name refer image below

Medicare Expiry date

Medicare Expiry Date refer image below

Healthfund + Number

Age Pension or DSP Card + Number

Aged Pension or Disability Support Pension cards only Please bring your card with you to your appointment for verification

Age Pension or DSP Card (if applicable)

Please confirm what type of concession card you have identified above

Message

please feel free to let us know any other relevant details

Electronic Communication

Dr Gellert makes use of SMS and email communication to confirm and remind patients of their appointments, recalls etc

I do NOT want to receive SMS communication

I do NOT want to receive email communication

Privacy Statement

As a patient of Dr Gellert, a medical record containing your personal information will be maintained trhoughout your treatment. Informstion of relevance is recorded in clinical notes which will be stored securely and kept 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 circumatances, there may be a legal obligation to disclose clinical information.

I give permission for Dr Gellert to pass on and to seek medical information from any medical practitioner, who has referred, treated or will treat me, if Dr Gellert determines that the exchange of information is necessary for my medical treatment. I also give permission for Dr Gellert to use Medicare Online Claiming and/or electronic account transmission on my behalf when required and I assign my rights to Medicare benefits to the practitioner who rendered the services.

medicare image.jpg — Medicare card details