Patient Information Registration

"*" indicates required fields

1Getting Started

2Step 1 - Information

3Step 2 - Questionaire

4Step 3 - Authorisation

Preparation

Our patient registration form streamlines your first visit to our practice by providing our specialists relevant information ahead of time.

You will need the following information available to complete this form:

Medicare number and card ID (if applicable)
Private Health Fund member number (if applicable)
GP Name & Address
Location of prior radiology scans (if applicable)
A scanned copy/photo of your Request/Referral Letter

Preferred Doctor

Preferred Doctor **

Personal Information

Title*

First Name*

Surname*

Patient Type*

Adult

Child

Known as

DOB*

DD slash MM slash YYYY

Home Phone

Mobile*

Work Phone

Email*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Postal Address (If different from aside)

Emergency Contact

Name*

Relationship to you*

Contact Number*

Email*

GP & Referrer

GP: Name*

GP: Address*

Street Address City State/Province ZIP/Postal Code

Referring Doctor (If different from above)

Medicare & Healthcare Fund

Do you have a Medicare Card?*

Yes

Medicare no.*

Reference on card*

Do you have a Health Fund?*

Yes

Health Fund*

Membership Number*

Have you been admitted to hospital in the last twelve months?*

Yes

Should we contribute your medical information to www.MyHealthRecord.gov.au?*

Yes

New Patient Paediatric Questionnaire

What problem/s is your child experiencing?*

New Patient Questionnaire

What problem/s brought you here?*

History of present illness

Please describe the location of your problem:*

Please describe the location of your child’s problem:*

How long have the symptoms been present (months/years)*

Do you have any drug/medication allergies?*

Yes

Does your child have any drug/medication allergies?*

Yes

What are you allergies?

What are your child's allergies?

Have you had any MEDICAL problems (diabetes, cancer, infections, etc) in the past?*

Yes

Please list any MEDICAL problems including the dates, if possible:*

Has your child had any MEDICAL problems (diabetes, cancer, infections, etc) in the past?*

Yes

Please list any MEDICAL problems your child has had including the dates, if possible:*

Have you had any SURGERIES in the past?*

Yes

Please list any SURGERIES that you have had in the past, including dates, if possible:*

Has your child had any SURGERIES in the past?*

Yes

please list any SURGERIES that your child has had in the past, including dates, if possible:*

Do you have asthma?*

Yes

Does your child have asthma?*

Yes

Do you use Inhalers?*

Regular use

Intermittent only

I don't use

Inhalers usage?*

Regular use

Intermittent only

I don't use

Do any diseases or cancers run in your family?*

Yes

Please list any diseases or cancers that run in your family:*

Radiology Scans

Have you had any x-ray, CT scans, MRI or other radiology related to this condition?

Yes

Radiology Group

Please select one or more providers where you have had radiology performed for this condition

Please provide your Radiology Clinic*

Current Medications

Are you currently taking any medication?

Yes

Does your child currently taking any medication?

Yes

Medications

Name

Dose

Frequency

Child's Medications

Name

Dose

Frequency

Additional Specialists (Audiologist, Physiotherapist, Endocrinologist, etc)

Additional Specialists (Pediatrician, Audiologist, Speech therapist, Respiratory, Endocrinologist, etc)

Additional Specialist:

None

Immunisation track

Are immunisations up to date?*

Yes

Social History

Occupation*

Does your workplace require:

Noise/hearing precautions?*

Yes

Mask/breathing protection?*

Yes

Heavy vocal/voice use?*

Yes

Use of smell?*

Yes

Have you ever smoked?*

Yes

Smoked within 12months?*

Yes

How many (cigarettes)/day?*

The age you started smoking(y/o)*

and quit(y/o)*

Do you drink alcohol?*

Yes

How many (drinks) /day?*

How many alcohol free days/week?*

Do you use recreational drugs?*

Yes

What kind?*

Any intranasal use?*

Yes

School year*

Does your child snore?*

Yes

Does your child have speech/language delays?*

Yes

Have behavioral issues?*

Yes

Guardian/Parent Name*

PERMISSION TO COLLECT AND STORE INFORMATION

Sydney Ear Nose & Throat Clinic. collects and stores personal and health information to provide safe and effective medical care. This may include your contact details, Medicare and health fund information, referral details, and clinical records relating to your assessment and treatment.

Your information is used primarily to manage your healthcare and may be shared with other health practitioners involved in your care (such as your GP or specialists) or disclosed where required by law. De-identified information may be used for quality assurance, audit, education, or research purposes.

As part of our clinical documentation process, Sydney Ear Nose & Throat Clinic. uses an AI-assisted clinical scribe to assist clinicians with preparing consultation notes and clinical correspondence. Your registration details may be processed using AI-assisted software to assist in booking. Medical professionals make clinical decisions, and your information is handled in accordance with Australian privacy laws.

Your medical records are stored securely and accessed only by authorised staff. Medical records are retained in accordance with legal requirements, generally for a minimum of seven (7) years from your last consultation, or longer where required by law (including for children). A copy of our full Privacy Policy is available on request.

We undertake only to collect information which is appropriate to your total care and to only use the information for its intended purpose. Your medical records are stored securely and can only be accessed by authorised staff. We are required to keep your records for up to seven years following your last consultation. If necessary, for the continuity of your medical care, this information may be shared with other health practitioners involved in your treatment. In certain circumstances there may be a legal obligation to disclose clinical information, for example to Government bodies. A full copy of our privacy policy is available here.

Attach Your Referral Please*

Drop files here or

Accepted file types: jpg, gif, jpeg, png, pdf, Max. file size: 10 MB, Max. files: 5.

Date*

DD slash MM slash YYYY

Signature*

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Central Coast Radiology
Clearview Medical Imaging
Dr Glenn & Partners Medical Imaging Kogarah / Dr Glenn & Partners Medical Imaging Rockdale / Dr Glenn & Partners Medical Imaging Wollongong
Harbour Radiology
Hunter Imaging Group
I-MED Radiology Network
Illawarra Radiology Group
Lakes Radiology
Life Medical Imaging
Lumus Imaging
Macquarie Medical Imaging
Mittagong Medical Imaging
Nepean Imaging / Nepean Radiology / Quantum Radiology
North Shore Radiology & Nuclear Medicine
Nowra Radiology
Oran Park Radiology
PRP Diagnostic Imaging
Qscan Radiology Clinics
Radiology Group
Regional I-MED (Wagga Wagga, Border and Riverina)
Shire Medical Imaging
South East Radiology / North Coast Radiology Group
South West Radiology
Specialist Radiology Group — Central Coast
Spectrum Medical Imaging
Superscan Radiology & Nuclear Medicine
Sydney Adventist Hospital — San Radiology & Nuclear Medicine
Sydney Imaging Specialists (formerly St Vincent’s Medical Imaging / SVMI)
Synergy Radiology
TrueScan Radiology
Vision XRAY Group
WD Imaging Group
Ashfield Radiology
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Clarity Imaging
The Cross Radiology
Focus Radiology (Engadine/Dapto/Liverpool
GXU Radiology
In Focus Radiology
NIA Radiology
Pulse Medical Imaging
Our Medical Imaging
Scanaptics
Wollongong Diagnostics
Canberra Imaging Group
I-MED Radiology Network
Lumus Imaging
Qscan Radiology Clinics
Bayside Radiology / Bolsover Radiology / Bundaberg Radiology
Cloud Radiology
Coastal Medical Imaging / Specialist Women’s Imaging Centre
Darling Downs Radiology
Exact Radiology Gatton / Exact Radiology Ipswich North / Exact Radiology Ipswich South / Exact Radiology Plainland / Exact Radiology Springfield Lakes
Gold Coast Radiology
I-MED Radiology Network / Wesley Medical Imaging
Imaging Queensland
Lumus Imaging
Mackay Radiology
North Queensland X-Ray Services
Qscan Radiology Clinics / ClinRad / Alpenglow Australia / Envision Medical Imaging
Queensland Radiology Specialists
Queensland X-Ray
Radiology Queensland Group Inala / Radiology Queensland Group Oxley / Radiology Queensland Group Underwood
South Coast Radiology
Sunshine Coast Radiology
Wide Bay Nuclear Medicine Bourbong / Wide Bay Nuclear Medicine Pialba
Capital Radiology
Direct Radiology
Epworth Medical Imaging
FMIG
I-MED Radiology Network
Imaging @ Olympic Park
Imaging Associates
Keystone Radiology
Lake Imaging
Lime Avenue Radiology
Lumus Imaging
Melbourne Radiology Clinic
ProRAD Medical Imaging
Radiology Victoria
Regional I-MED (Gippsland, Wangaratta and Border)
The X-Ray Group
Victoria House Medical Imaging
Vision Radiology
Western Medical Imaging
Benson Radiology
Capital Radiology
Fowler Simmons Radiology
Jones Radiology
Light Radiology
Lumus Imaging
Precision Radiology
Qscan Radiology Clinics
I-MED Radiology Network
Jones Radiology
Regional I-MED (Darwin)
Capital Radiology
I-MED Radiology Network
Qscan Radiology Clinics
Radiology Tasmania
Regional I-MED (Tasmania)
Tasmania Imaging
Apex Radiology
Capital Radiology
I-MED Radiology Network
Lumus Imaging
My Radiology Centre
Perth Radiological Clinic
Qscan Radiology Clinics
SKG Radiology
Other