The ENT Clinic patient registration form Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Date of BirthEmail Telephone (Home)Telephone (Mobile)Address Street Address City Postal Code Indigenous StatusAboriginalTorres Strait IslanderNeitherNot stated(Select all that apply)Medicare NumberRef#Expiry DatePrivate Health FundPrivate Health Membership numberVeterans' Affairs (if applicable)Card TypeGoldWhiteBlueNext of kinTelephone numberParent / Guardian details(If patient is under 18 years old)Name First Last Address Street Address Postal Code Phone (if different from above)Email (if different from above) Medicare NumberRef# FEE Medicare rebate Out of pocket (estimate) New patient $210 $73.85 $136.15 Review patient $100 $37.15 $62.85 Flexible endoscopy $190 $104.45 $85.55 Aural toilet $150 ($75 2nd ear) $93.45 ($46.72 2nd ear) $56.55 ($28.28 2nd ear) Nasal cautery $125 $76.50 $48.50 Fees correct as of 01.05.2019 Fee ScheduleCAPTCHA
