Forms

Patient Registration Form


When completing the registration form, please note that the name must be as it appears on your Medicare Card.


Patient Details

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Medicare Details

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Concession Details

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Your Medical Professionals

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Private Health Insurance Fund Details


Emergency Contact

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Your Medical History

Please tick where applicable.

General Health

Eye History

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Terms & Conditions

Please Note: This practice does not bulk bill. Payment is required on the day of consultation.

Government regulations require a current letter or referral from a general practitioner or optometrist to claim your rebate back from medicare.

The provision of quality health care requires doctor-patient relationship of trust and confidentiality. Consistent with our commitment to quality care this practice has developed a policy to protect patient privacy in compliance with privacy legislation.

The Cairns Eye & Laser Clinic would like you to be aware of the following: In the collection of your personal information, there may be times where another health party will need to have information about you in order to provide a complete, holistic approach to your health care. There are some necessary purposes of collection for which information will be used beyond providing health care, such as professional accreditation, clinical auditing, finalization of accounts and so forth.

Should you have any queries, please feel free to read our Privacy Policy, “Your Privacy – Our Policy” or speak directly to your doctor or one of the staff. If at any time you feel uncomfortable with regard to the collection of your personal information, please feel free to mention it.

In proceeding with submission of this form, you agree to our Privacy Policy on the collection of your personal information and in the event of a debt you agree to pay any commission generated on the debt collected on your behalf by our nominated debt collection agency.

New Patient Information Letter & Practice Brochure *

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