Dr Kenneth Buxey - Patient Registration Form

Patient Details

First Name *

Last Name *

Sex assigned at birth

MaleFemale

Date of Birth *

Is the patient 17 years or younger *

YesNo

Guardian NAME *

Knowing your cultural background can help us provide healthcare that meets your individual needs. Are you Aboriginal or Torres Strait Islander origin?

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNone of these

Patient Contact Details

Mobile Phone

Home Phone

Email

Street Address

City / Suburb

State

Postcode *

Next of kin, carer, support person

Next of kin, carer, support person name

Mobile number

Does your carer or support person assist you with your appointments? *

NoYes - We can contact them as well, to assist with your appointments

Add another carer or support person contact

Second support person NAME

Second support person PHONE NUMBER

Medicare

Numbers only no spaces required

This is the single digit number next to your name on the medicare card.

Numbers only no spaces required

This is the single digit number next to your name on the medicare card.

Do you use a different name on your Medicare card? *

NoYes - Please complete the details below

Full Name as printed on your Medicare card

Private Health Insurance

Provider

Membership No.

Expiry(mm/yyyy)

Have you changed private health funds within the last twelve (12) months *

YesNo

I understand I will need to confirm the end date of any new waiting period for hospital cover by my nominated health fund

*

I understand private health funds may cover the hospital fee only. Separate fees apply for the consultation, surgeon and anaesthetist, and review appointment/s as required *

Pension / HCC / DVA Card

Do you have an aged pension card, healthcare card or a DVA card *

NoYes - Please complete the details below

Card Type

HCCPension

Card No.

Expiry(mm/yyyy)

DVA No.

GP / Medical Centre

PLEASE NOTE: Specialist referrals including hospital admissions are only valid for three (3) months. Please ensure you have your GP send an updated referral to Dr Buxey at Telecare Online to entitle you to Medicare rebates ongoing for twelve (12) months
*If your referral lapses you will no longer be entitled to these Medicare rebates and you accept responsibility for the full private fees.

If you have NOT submitted a GP referral, please complete these details below

Medical Centre Name and Location *

GP Name

Medical Centre Phone Number

Are you a returning or referred patient of Dr Anton Iseli (who has now retired)?

Yes - Returning patient of Dr Anton's (have had consultation/s with Dr Anton in the past)Yes - New patient to Dr Anton (have been referred to but have not seen him before)No

Are you booking another colonoscopy

YesNoNot sure

Indications for colonoscopy *

Preferred Local / Regular Pharmacy for Medication

Do you have a preferred local pharmacy for obtaining medications? *

NoYes - Please complete the details below

Pharmacy Name and Location

Pharmacy Email

Pharmacy Phone Number

Workers' Compensation

Are you seeking this assessment/treatment due to a workplace injury/illness? *

NoYes - Please complete the details below

Do you have an accepted claim for workers' compensation

NoYes

Depending on your state jurisdiction, you may need approval from your claims agent for specialist and allied health services. Please confirm approval of your service with your claims agent, or request your claims agent to email us with your approval: data@telecare.com.au

Claims Agent

State/territory (jurisdiction you were injured in)

Case Manager

Case Manager Email

Claim document

Browse

Upload a PDF or document with evidence of an approved work cover claim

Cancellation Policy

Please understand that our specialists have reserved their time for you. If you must cancel your appointment, we respectfully request 48 hours notice so we have time to organise another patient who needs this service.

Missed appointments, or appointments cancelled without valid medical reason within 48 hours of the appointment, will incur a fee equal to the bulk-billed fee amount (max $150).

Yes, I agree.

*

Consent to provide information

Obtaining medical information

As part of providing a clinical service to you, Telecare's specialist or allied health provider will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the assessment and treatment that is conducted.

Purpose of collecting and holding information

The information is gathered as part of the assessment and is seen only by your provider and Telecare staff. The information is retained to document what happens during sessions and enables the provider to provide a relevant and informed clinical service.

Access to Client Information

At any stage you as a client are entitled to access to the information about you kept on file unless the relevant legislation provides otherwise. The provider may discuss with you appropriate forms of access.

Confidentiality

All personal information gathered by the provider during the provision of the service will remain confidential and secure except where:

It is subpoenaed by a court, or
Failure to disclose the information would place you or another person at serious risk/danger/harm; or
To provide a written report to another professional or referring agency eg. a GP to discuss the material with another person, eg. a parent or if disclosure is otherwise required or authorised by law. It is a Medicare requirement that progress reports be sent to the referring GP.

Yes, I agree.

*

Consultation Fee Consent

As part of the booking process, it is mandatory for you to provide your credit card / debit card details to our secure payment portal here via Eway. If you have any queries, please contact us via 03 9018 6674 *

You accept the Medical Consultation fee/s provided to you during the booking process and will contact Dr Buxey's booking team (Telecare) to clarify fees and payment options if required and at least 48 hours prior to an appointment/s. You understand that Telecare will collect your card details via Eway, an Australian based secure payment pathway. You can request to update or remove your details at any time in writing by emailing: admin9@telecare.com.au

You agree your payment method will have sufficient funds to pay the full fee, and consent to Telecare using your collected card details for payment of any follow up consults you book and attend.

If a payment is declined, you may be subject to a late payment adminstration fee.

*

LATE CANCEL or NO SHOW
You understand that our specialists have reserved their time for you. If you must cancel your appointment, we respectfully request 48 hours notice so we have time to organise another patient who needs this service. Missed appointments, or appointments cancelled without valid medical reason within 48 hours of the appointment will incur a fee ($150).
*

Credit card surcharge applies (1.7% + 20c per transaction). Alternate payment methods can be discussed on booking.

Consultation Fee Payment Details *

SIGNATURE

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

Patient/ Guardian Signature

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Today's Date

Contact Information

How Telecare Manages Your Information

For any enquiries plea se contact us on

Phone: 03 9018 6674

Email: reception@drkennethbuxey.com.au

Access Telecare's Privacy policy here https://telecareonline.com.au/terms

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