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	$76.15	$133.85
Review (105)	$100	$38.25	$61.75
Endoscopy (41764)	$190	$107.70	$82.30
Ear toilet (41647)	$150 ($75 2nd ear)	$96.35 ($48.20 2nd ear)	$53.65 ($26.80 2nd ear)
Nasal cautery (41677)	$125	$78.90	$46.10

*Fees correct from 1st July 2020 and may be subject to change without prior notice

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