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 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) $225.00 $76.15 $148.85 Review (105) $115.00 $38.25 $76.75 Endoscopy (41764) $210.00 $107.70 $102.30 Ear toilet (41647) $160.00 ($80 2nd ear) $96.35 ($48.20 2nd ear) $63.65 ($31.83 2nd ear) Nasal cautery (41677) $140.00 $78.90 $61.10 *Fees correct from 24th May 2021 and may be subject to change without prior notice Fee ScheduleCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
