Patient Registration | Northern Eye Consultants Bundoora

Patient Registration

Complete your registration before your appointment — it only takes a few minutes.

Please complete this form before your appointment. Your information will be securely transmitted to our reception team and will help us prepare for your visit.

1. Personal Details

Title

First Name *

Preferred Name

Family Name *

Date of Birth *

Postal Address

Home Phone

Mobile Phone *

Email Address *

2. Medicare & Government Entitlements

A Medicare card is required to access Medicare rebates. Please bring your card to your appointment.

Medicare Number *

Please enter your Medicare number as it appears on your card.

Medicare Reference Number

The number that appears in front of your name on the card.

Medicare Expiry Date

Month

Year

Government Pension Card

DVA Member

3. Private Health Insurance

Do you have private health insurance?

4. Referring Practitioners

General Practitioner

GP Name

GP Practice Name

GP Address

GP Phone

Optometrist

Optometrist Name

Optometrist Practice Name

Optometrist Address

Optometrist Phone

5. Next of Kin

Next of Kin Name *

Relationship to Patient *

Next of Kin Contact Number *

6. Practice Policies

Privacy Statement

As a patient of Northern Eye Consultants, a medical record containing personal information will be maintained throughout your treatment. These records will contain information including, but not exclusive to, your name, address, date of birth, Medicare number and your referring doctor's details. During the period of assessment and ongoing management, information of relevance is recorded in clinical notes. These records are stored securely and may be kept 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. Scans & photos may also be used for educational and training purposes. In this instance your identity and personal details will be withheld & protected. Please advise your doctor if you do not consent. A full copy of our privacy policy is available on request.

Notice Regarding AI-Assisted Documentation and Recording

To support accurate medical documentation and improve the quality of your care, doctors in this practice may use AI-assisted recording devices during consultations. These tools securely capture and transcribe relevant information from the discussion to help create clinical notes.

Your privacy and confidentiality remain a priority, and any recordings or transcripts are handled in accordance with applicable privacy and health information regulations.

Please note that patients and accompanying persons are not permitted to record consultations (including audio, video, or photographs) without the explicit permission of the doctor.

If you have any questions or concerns about the use of AI-assisted documentation, please speak with our staff before your consultation.

I confirm that I have read and understand the Privacy Statement and Notice Regarding AI-Assisted Documentation and Recording above, and I agree to these policies. *

7. Declaration

Northern Eye Consultants is not a bulk billing clinic. Consultation fees are payable on the day of your appointment.

I confirm that the information provided above is accurate and complete to the best of my knowledge. *I consent to Northern Eye Consultants collecting and storing my personal and health information in accordance with their Privacy Policy. *

Fields marked * are required.