Patient Registration Form

Please complete this form if you are a new patient to Ultrasound Care or if your details have changed since your last visit. Alternatively, if you prefer, you may complete this form at our practice when you attend for your appointment.

First Name

Last Name

Medicare Number

Card ID

Date of Birth

Home Phone

Work/Mobile

Preferred Contact Method

Home Phone Work/Mobile Email

Address

Suburb

Postcode

Location for my scan is:

Address

Level 2
15 Bowden Street, Alexandria NSW 2015

Phone

(02) 9690 2744

Address

Suite 1603, Level 16
101 Grafton Street, Bondi Junction NSW 2022

Phone

(02) 8383 4100

Address

Ground floor
170 Pacific Highway, Greenwich NSW 2065

Phone

(02) 9439 9711

Address

Suite 3, Level 7
139 Macquarie Street, Sydney NSW 2000

Phone

(02) 9251 7799

Address

Suite 1
20 Bungan Street Mona Vale NSW 2103

Phone

(02) 9998 5100

Address

RPA Medical Centre
412/100 Carillon Avenue, Newtown NSW 2042

Phone

(02) 9519 0999

Address

2 Hay Street, Randwick NSW 2031

Phone

(02) 9314 8999

Address

Sydney Adventist Hospital
Level 3, 185 Fox Valley Road, Wahroonga NSW 2076

Phone

(02) 9487 9800

PATIENT CONSENT TO RELEASE INFORMATION

Patient reports are released to the following people:

Your referring doctor
Your GP or Specialist
Hospital Emergency Department Doctors
Your Antenatal Clinic or Birthing Centre
Medicare (when requested and legally required for audit purposes)

Ultrasound Care and SAN Ultrasound for Women use the same Picture Archiving and Communication System (PACS). Images performed at these practices are available for review by the sonologist interpreting your study.

Do you consent to your de-indentified images being used for teaching, education, scientific communication purposes?

Yes No

Do you consent to your de-identified images being used for social media?

Yes No

FILMS & RESULTS

When is your next doctor's appointment?

Date

Time

Note: Because of Medicare requirements patient reports cannot be withheld from referring doctors.

Which additional doctors or clinics would you like a copy of your report sent to?

Name

Will you bring any old films with you on the day of your appointment?

Yes No

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PATIENT CONSENT TO RELEASE INFORMATION

FILMS & RESULTS

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