Patient Registration | ENT Clinic Melbourne | Dr Charles Giddings & Associate Professor Joanne Rimmer

The ENT Clinic patient registration form

Name
Prefix First Last
Date of Birth
Email
Telephone (Home)
Telephone (Mobile)
Address
Street Address City Postal Code
Indigenous Status
- Aboriginal
- Torres Strait Islander
- Neither
- Not stated
(Select all that apply)
Medicare Number
Ref#
Expiry Date
Private Health Fund
Private Health Membership number
Veterans' Affairs (if applicable)
Card Type
- Gold
- White
- Blue
Next of kin
Telephone number
Parent / 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 Number
Ref#

	FEE	Medicare rebate	Out of pocket (estimate)
New patient (104)	$210	$75.05	$134.95
Review (105)	$100	$37.70	$62.30
Endoscopy (41764)	$190	$106.10	$83.90
Ear toilet (41647)	$150 ($75 2nd ear)	$94.45 ($47.23 2nd ear)	$55.55 ($27.77 2nd ear)
Nasal cautery (41677)	$125	$77.75	$47.25

*Fees correct from 1st August 2019 and may be subject to change without prior notice

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