The ENT Clinic patient registration form Name* Mr.Mrs.MissMs.Dr.Prof.Rev. 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 Date of Birth Address Street Address Postal Code Phone (if different from above) Email (if different from above) Medicare Number Ref# By submitting this form, I acknowledge the Consulting Fees and agree with my information being held by The ENT Clinic. Please contact the front desk staff prior to submitting this registration should you have any queries.* Yes FEE Medicare rebate Out of pocket (estimate) New patient (104) $225.00 $76.80 $148.20 Review (105) $115.00 $38.60 $76.40 Endoscopy (41764) $210.00 $108.65 $101.35 Ear toilet (41647) $160.00 ($80 2nd ear) $97.20 ($48.60 2nd ear) $62.80 ($31.40 2nd ear) Nasal cautery (41677) $140.00 $79.65 $60.35 Videostroboscopy (41501) $255.00 $164.15 $90.85 Intratympanic steroids $250.00 $127.40 $122.60 Skin Lesion Biopsy (30071) $125.00 $46.20 $78.80 Oral Cavity Lesion Biopsy (45801) $250.00 $112.30 $137.70 *Fees correct from 06 December 2021 and may be subject to change without prior notice Fee Schedule CAPTCHANameThis field is for validation purposes and should be left unchanged.
