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#Veterans' Affairs (if applicable)GoldWhiteBlueDo you have private health insurance with hospital cover? Yes No Name of FundMembership numberNext of kinTelephone numberParent / Guardian details(If patient is under 18 years old)Name First Last Date of birthAddress Street Address Postal Code Medicare NumberRef# FEE Medicare rebate Out of pocket (estimate) New patient $200 $72.75 $127.25 Review patient $100 $36.55 $63.45 Flexible endoscopy $180 $104.45 $75.55 Aural toilet $140 ($70 2nd ear) $93.45 ($46.75 2nd ear) $45.55 ($23.25 2nd ear) Nasal cautery $120 $76.50 $43.50 Fee ScheduleCAPTCHA
