Serving Above and Beyond…… we carE

Patient Registration Form

Personal Details:

Gender:

Date of Birth:

PRIVATE HEALTH INSURANCE:

AGED PENSIONER:

VETERANS AFFAIRS:

CONSENT **** Please read carefully as it contains important information******
* I consent to the collection, usage, disclosure and storage of my personal information in accordance with the National Privacy Principles defined under the Privacy Act 2010.
* I understand that I will have to pay for DR Khokhar’s Doctors services, even if I am admitted to hospital and cared for by another doctor or specialist
* I consent to DR Khokhar to share information about my visit to my usual GP.
* I consent to my GP/other doctors sharing information about me with DR Khokhar.
* I understand that I am responsible for tests such as X-rays, blood test and other scans.

Date: