Welcome to Cura Medical Specialists, new patient registration form. Our aim is to provide you with the best possible healthcare. Please complete all sections and read the Personal & Health Information Consent section at the end of this form.

Should you have any queries please speak with reception or your practitioner.

This form is best filled out on a web browser on a computer but can be done on a mobile phone as well.

Have you made an appointment with us already?

YesNo - I would like you to call me to arrange an appointment

Do you have a valid referral ?

YesNo - But I will get one 3 days before my appointment.

What is the date of your appointment? *

How did you find our clinic? *

I or someone else found you on a Google I or someone else found you on a Health DirectoryMy GP recommended I see youA patient of ours (e,g friend or family) recommended I see youI was referred by another specialist

Contact Details

Title *Mr / Mrs etc etc

First Name *

Last Name *

Middle Name

Preferred Name

Date of birth *

Gender *

Mobile Phone Number *

Home Phone

Email Address *

Address

Residential Address *

Suburb *

State

Postcode *

Health Funds & Insurance

Invoice - Account type *

Self (including Medicare, ADF rebates)Other (including Comprehensive Third Party Insurance (CTP) and Workers Compensation (WC))

Do you have a Medicare card? *

YesNo

I would like to: *

Take a photo of my Medicare CardEnter my Medicare Number manually

What is your Medicare Number? *

Medicare Individual Ref Number *

Medicare Expiry Date (Month/Year) *

Please upload a photo of your Medicare Card *

Browse

Insurer *

Claim Number

Name of Case Manager *

Phone Number of Case Manager *

Email of Case Manager

General

Indigenous status *

AboriginalTorres Strait IslanderNeither

Health Team Members/GP

Full Name of your GP *

Address or Name of Practice *

Phone *

Emergency Contacts

Name *

Phone Number *

Will the emergency contact person be signing the personal and health information consent for the patient as the legal guardian or parent?

YesNo

Personal and Health Information

We respect your rights to privacy and take our privacy obligations seriously. We comply with the Australian Privacy Principles, found under the Privacy Act 1988 (Cth).

OurPrivacy Policycan be obtained from:

Website: www.curaspecialists.com.au
Reception: 3.2/135 Victoria Rd, Drummoyne NSW 2047
By calling: 02 7906 8356

We will typically send copies of our clinical reports to you as well as your referring specialist or GP. How would you like to receive these clinical reports? *

EmailI do not wish to receive a copy my clinical reports

I confirm that the provided e-mail address is my secure, personal account or that of an authorised person. I consent to the use of e-mail to send documents to this personal address and my health care providers.
*

I confirm that the provided e-mail address is my secure, personal account or that of an authorised person however I DO NOT WANT my health documents sent to this address. However, I acknowledge that CURA Medical Specialists have taken all reasonable steps to securely e-mail my records to my nominated health care providers.
*

Would you like your specialist letters/reports sent to your My Health Record? *

YesNo

I give consent for my personal and health information (tick all that apply): *

To be communicated to or accessed from third parties, including the Medicare Australia, private health insurers, government departments and other practitioners involved in your healthcare for the purposes of delivering healthcare to you;To be used in discussions with other public health professionals, education or research (your information will be deidentified and securely communicated)To manage our practice, such as conducting audits and undertaking accreditation processes, manage billings and training staff;To authorise the practitioner, who will render services, to submit my unpaid or partially paid account to Medicare. I understand that Medicare will assess my claim and issue a cheque to the practitioner for the Medicare benefit. (you will be advised of any additional out-of-pocket costs before booking)To be accessible to you securely via your Patient Portal with our practice.

As the legal guardian or parent, I give consent for the patient's personal and health information; (tick all that apply) *

To be communicated to or accessed from third parties, including the Medicare Australia, private health insurers, government departments and other practitioners involved in your healthcare for the purposes of delivering healthcare to you;To be used in discussions with other public health professionals, education or research (your information will be deidentified and securely communicated)To manage our practice, such as conducting audits and undertaking accreditation processes, manage billings and training staff;To authorise the practitioner, who will render services, to submit my unpaid or partially paid account to Medicare. I understand that Medicare will assess my claim and issue a cheque to the practitioner for the Medicare benefit. (you will be advised of any additional out-of-pocket costs before booking) (you will be advised of any additional out-of-pocket costs before booking).To be accessible to you securely via your Patient Portal with our practice.

I have read the information above and understand why my information is collected and how it is used. I acknowledge that I am not obliged to provide any information requested of me, but that failure to do so might compromise the quality of care provided to me *

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As the legal guardian or parent, I have read the information above and understand why the patient's information is collected and how it is used. I acknowledge that I am not obliged to provide any information requested, but that failure to do so might compromise the quality of care provided to the patient. *

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Please let us know if you had any issues or dislikes with the form.

Security Check *

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