Registration form - Dr Cunnington

Name(Required)

First Last

Address(Required)

Street Address Suburb / City State Post Code

Email(Required)

Mobile (if no mobile, list landline number)(Required)

Date of birth(Required)

Gender(Required)

Male

Female

Identify as other

Medicare Number (10 digits)

Note - if Medicare details are not provided, we won't be able to process claims for Medicare rebates on your behalf.

Your Number on Medicare Card

Please enter a number from 1 to 9.

Do you have a healthcare or pensioner concession card?

Yes

Healthcare card number

Expires

Pensioner concession number

Expires

Do you have private health insurance?

Yes

Health Fund

Policy Number

If you have a referral letter, or other relevant documents, please upload them here (if you have a smartphone take a photo):

Drop files here or

Max. file size: 8 MB.

Please add any particular information you would like us to know prior to your appointment

I understand that fees apply for consultations and that payment must be made on the day of the appointment.(Required)

Yes

I consent to the use of my Medicare number for billing and claiming by the practice, and to access and upload information to my 'My Health Record' to support clinical care.(Required)

Yes

Our practice uses Medicare Online services and is connected to My Health Record to improve the quality and safety of care.

I confirm that I am the person named above and I am registering on my own behalf, or I am registering a dependent.(Required)

Yes

If you have questions about registering as a new patient, please email reception@drdavidcunnington.com.au or call 03 8609 0308.

If you have questions about registering as a new patient, please email or call 03 8609 0308.

Dr David Cunnington and associates take obligations under the Victorian Health Records Act 2001 and the Commonwealth Privacy Act 1998 seriously and take all reasonable steps in order to comply and protect the privacy of the personal information that is held. A copy of our privacy policy can be downloaded here.