Patient Registration Form

New patients, please fill out our online form below.

Alternatively, if you would prefer to print off and fill out our form by hand please click the button below and send to either Email hello@metroent.com.au
or Fax (03) 8658 0936

Registration form (PDF)

Please enable JavaScript in your browser to complete this form.

Patient Details

at ENT I

First Name *

Last Name *

Patient Date of Birth *

Occupation *

Gender *

Your Gender (specify)

Address *

Suburb *

Postcode *

State *

Mobile *

Phone

Email *

Please provide your mobile number as we will send SMS messages regarding your referral and appointments.

Do you identify as Aboriginal or Torres Strait Islander (ATSI) *

Have you seen Dr Freitas before? *

If so, at which location did you see him?

Medicare / Pension Information

Medicare Number

Medicare Ref Number

Medicare Expiry Month

Medicare Expiry Year

Pension Card Number

Pension Card Expiry Month

Pension Card Expiry Year

Private Health Insurance

Private Health Insurance *

Hospital Cover *

Time with health fund less than 12 months *

Private Health Fund

Health Fund Membership Number

Emergency contact / Next of kin / Primary caregiver / Account holder

Emergency First Name *

Emergency Last Name *

Emergency Relationship

Emergency Date of Birth

Emergency Phone

How did you hear about us? *

Please specify

Referring Doctor or Allied Health Professional

Referring Doctor 1 - Prefix

Referring Doctor 1 - First name

Referring Doctor 1 - Last Name

Referring Doctor 2 - Prefix

Referring Doctor 2 - First name

Referring Doctor 2 - Last Name

Referring Clinic Name(s)

Primary concern to see doctor

Usual GP

Usual GP - Prefix

Usual GP - First name

Usual GP - Last Name

GP Clinic Name

Primary concern to see GP

Other Doctors or Allied Health Professionals

Upload Referral here

Drag & Drop Files, Choose Files to Upload

Upload any other relevant documents here (including imaging, audiology, pathology or sleep study results)

Drag & Drop Files, Choose Files to Upload

Consent

I agree to Metro ENT passing on my personal details and medical information to other clinicians, hospitals, medical services, and other admin staff who may be based overseas if necessary for my care. I also consent to the release of health information (including test results, etc) about past and present illness to the doctor making this request. I understand this is necessary for my ongoing treatment. *

I agree to Metro ENT passing on my personal details and medical information to other clinicians, hospitals, medical services, and other admin staff who may be based overseas if necessary for my care. I also consent to the request of information (including test results, etc.) about past and present illness from my doctor or health provider. I understand this is necessary for my ongoing treatment.

I have read and understood the Fee Schedule. I understand that any procedures performed on the day of my consultation will incur additional charges beyond the standard consultation fee. *

I have read and understood the Fee Schedule. I understand that any procedures performed on the day of my consultation will incur additional charges beyond the standard consultation fee.

I consent to Metro ENT's use of medical transcription software to assist in documenting clinical notes. This tool helps health practitioners record accurate notes during patient consultations by listening in the background and capturing only relevant details for clinical documentation. These details are then transcribed into text and sent to your health practitioner’s Electronic Medical Record system. *

Name *

Relationship *

Signature *

Clear Signature

Todays Date *

Get in touch

2/214 Bay Street Brighton Vic 3186 – Google Maps

(03) 8658 0908

Speak to a friendly member of our staff

In the spirit of reconciliation Metro ENT acknowledges the Traditional Custodians of Country throughout Australia and their connections to land, sea and community. We pay our respect to their Elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

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