CLMRAD New Patient Registration

To ensure that we can provide the best quality care, please complete the details below.

Coolum Radiology complies with the Australian Privacy Principals (APP).

This means that your personal health information is kept private and secure as federal and state privacy laws require. Our privacy policy can be found on our website.

Patient details

First Name *

Middle Name

Last Name *

Preferred Name

Date of Birth *

Patient contact details

Address *

City / Suburb *

State *

Postcode *

Best Contact Phone Number *

Work Phone

Email *

Parent, legal guardian, caregiver for paediatric patient (under 16 years of age)

Full Name

Relationship to patient

ParentCarerGuardian

Best Contact Phone Number

Work Phone

Referring Doctor

Referring Doctor’s Name

Address

Medicare

You are ineligible to claim a Medicare rebate if you do not have a Medicare Card.
You may be able to claim via your travel/private insurance.

Do you have a Medicare Card? *

YesNo

Medicare Card No. *

Ref *

Expiry *

DVA Card

Do you have a DVA card *

YesNo

DVA Card Type

GoldWhite

DVA No. *

Expiry Date *

Pension or Health Card Card

Do you have a Pension or Health Care Card? *

YesNo

Card Type

HCCPension

Card No: *

Expiry date *

Additional Medical Information

Do you have any allergies or intolerances? *

YesNo

Please list allergies or intolerances *

Do you use any blood thinning medication(s) or blood thinning supplements? *

YesNo

Please list: *

Worker's Compensation, MVA, Insurance or Legal Claim

Is you diagnostic procedure in relation to any of the above claim types? *

YesNo

Claim Type - choice *

Works compensationMotor vehicle accidentInsurance or legal claim

Do you have confirmation that your claim has been accepted? *

YesNo

If your claim has been accepted, plesae tell us your claim number: *

Financial consent declaration by patient or guardian

Coolum Radiology is a private radiology practice and requires full payments on the day of your appointment unless eligible to be bulk billed to Medicare or DVA, or you have an approved worker's compensation/MVA/insurance claim.

I understand that the examinations required may incur some costs, including out-of-pocket expenses to myself.

I understand that if Medicare/DVA/Workers Compensation or any other nominated third party does not refund/pay for these services, then it is my responsibility to pay the full cost of this examination.

Please discuss any fees with our friendly team. Patients who do not attend appointments may be charged a cancellation fee.

I understand and acknowledge that it is my responsibility to pay the full amount owing for diagnostic services, examinations and procedures for today and any future appointments. *

I confirm that the information I have provided is true, complete, and accurate. *

Patient/ Guardian Signature

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