NEW PATIENT REGISTRATION FORM

    Personal Details

    Title:

    Gender:

    Medicare Details

    Are you eligible for Medicare benefits?

    Private Health Insurance

    Do you have Private Health Insurance?

    Does your policy include hospital cover?

    Have you completed your waiting period?

    Allergies

    Do you have any allergies?

    Referring GP Details

    Emergency Contact Details

    Relative Healthcare Providers

    Physiotherapist / Allied Health

    Other Specialist

    Workers Compensation / Third Party Claims

    Is your condition related to:

    If so, please provide details:

    Consent & Privacy Policy

    This practice collects personal and health information to provide medical care and treatment. Your information may be used for:

    • Medical diagnosis and treatment

    • Administrative purposes and billing

    • Communication with other healthcare providers involved in your care

    • Referrals for diagnostic testing and specialist services

    Your information will be handled in accordance with the National Privacy Principles and the Health Records and Information Privacy Act 2002 (NSW).

    We may disclose relevant health information to:

    • Your referring doctor and usual GP

    • Other specialists or allied health professionals involved in your care

    • Pathology and radiology providers

    • Hospitals or day surgery facilities if required

    • Medicare, private health insurers, or third-party insurers where applicable

    You have the right to request access to your personal health information and to request corrections if necessary.

    Our practice uses Lyrebird AI technology to monitor, record, and dictate consultations. Please advise in writing to admin@drpeterlorentzos.com.au if you do not wish for Lyrebird to be used during your appointment with Dr Peter Lorentzos.

    Patient Declaration

    I confirm that the information provided is accurate and complete to the best of my knowledge. I consent to the collection and use of my personal and health information as outlined above for the purpose of providing medical care and related administrative services.

    Patient Consent: