Details Form

Personal Details

Title

Birth Sex

Gender Identity

Name *

First

Middle

Last

Date of Birth *//

Address Details

Residential Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Postal Address

Please tick if same as above

Postal Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Home Phone

Mobile

Work Phone

Language / Nationality Details

Country of birth *

Language Spoken *

Do you identify as: *

Aboriginal
Torres Strait Islander
Aboriginal & Torres Strait Islander
Neither

Will an interpreter be required?

Do you require the services of the NRS for hearing & speech impaired?

Concessions & Private Health Details

Medicare Card No.

Medicare Expiry Date//

IRN Number (number next to your name)

Concession Card No.

Concession Expiry Date//

DVA Card No.

DVA Expiry Date//

DVA Card Type

Gold
White

Private Health Fund

Private Health Member No.

If you are under 17 years of age please fill out the below medicare details for billing purposes

Parent Full Name

Medicare Card No.

Medicare Expiry Date//

IRN Number

Next Of Kin Details

Next of Kin: Full Name

Next of Kin: Relationship to Patient

Next of Kin: Mobile

Next of Kin: Landline

Emergency Contact:

Same Details as Next of Kin

Emergency Contact: Full Name

Emergency Contact: Relationship to Patient

Emergency Contact: Mobile

Emergency Contact: Landline

Medical Details

Please list any allergies: food, medications, dressings etc: (Please also state reaction experienced & severity) (Only Leave blank if NIL KNOWN)

Consent Details

Reminders & Recalls: Do you consent to SMS from Dernancourt Medical Centre?

Please also be aware that while we offer a recall service for some pathology and reports received, it is still the responsibility of the patient to contact us regarding obtaining results.

Payment of Accounts:

I have read and accept the terms following

Please note, our practice utilises TYRO for claiming and payments of services. Unless arranged prior to your appointment, this requires the full consult fee (including any non-reimbursable gap payment), to be paid on the day. All Pension, Concession Health Care Card holders, DVA Card holders and children under 17 years will be Bulk Billed

It is the policy of the practice to only provide results to yourself or any relevant practitioners involved in your treatment for specific reasons (e.g. referred Specialists, Allied Health, compensation providers etc.). If you wish to authorise any other representative on your behalf Please list them below

Privacy and Security of Health Records *

I consent to the collection and use of my information by this practice

On occasion details regarding your health may be shared with relevant third parties pertinent to your healthcare needs; all necessary measures will be met to ensure your privacy and confidentiality. The National Privacy Principles in the Privacy Act sets out how this Practice should collect, use, keep secure and disclose personal information. A copy of our Privacy Policy is available for all patients which outlines the terms in which your health information is managed and utilised.

Referral Upload

Click or drag a file to this area to upload.

Do you have a copy of your referral? Please take a photo of it and upload it so we enter all your information before your appointment. Please also bring your referral on the day

How did you hear about us?

Family / Friends
Social Media
Previous Patient of Dr Lalith
Other

File Upload

Click or drag a file to this area to upload.

Message

For an Appointment at Dernancourt Medical Center, Call (08) 7095 0325

Contact Us

Services

Our Team

Patient Info

Other Services

IMPORTANT NOTICE

If you have cold or flu type symptoms we kindly ask that you still wear a mask, or wait outside before your appointment. Many Thanks from the Dernancourt Medical Team