Registration Form


    Medicare Number :
    Medicare Ref No. :  


    Concession Card(if applicable) :  
    Concession Type :  


    If you don't have Medicare
    Private Insurance Company :  
    Private Insurance Type :  
    Private Insurance Policy Number :  


    Title:       Sex :  
    First Name :   Surname :  

    Birth Date :  

    Residential Address(with unit number if applicable):  
    Suburb :  
    Post Code :  
    Mobile Phone :  
    Home Phone :  
    Email :  


    CULTURAL BACKGROUND
    Do you identify as being Aboriginal :  
    Do you identify as being Torres Strait Islander :  
    Country of Birth :  
    Ethnicity :  
    Language Spoken :  
    Preferred Language Spoken :  


    Details of Your NEXT OF KIN
    Name :  
    Relationship to Patient :  
    Phone Number :  


    Details of Your EMERGENCY CONTACT (if different)
    Name :  
    Relationship to Patient :  
    Phone Number :  


    (Please read this consent and agreement carefully prior to sign):
    1) I understand that collecting my personal information and medical history is required to ensure high quality healthcare, accurate Medicare/Insurance billing and referral to other specialists.
    2) I shall inform AIM Health if there are any changes to my contact details, such as address and phone/mobile number. If I am unable to contacted, I understand that I am responsible for any associated consequences.
    3) I consent for AIM Health to send me reminders via SMS, phone call, letter or email.
    4) I agree that I need to make an appointment to discuss my result, and/or, obtaining a referral, prescription, medical certificate, mental health care plan or EPC, etc.
    5)I understand that AIM Health requires at least 24 hours’ notice to cancel or reschedule an appointment. Failure to do so may result in a cancellation fee of $30, which needs to be paid within 7 days.
    6) I am aware that there will be an administration fee to transfer/obtain my medical records, which needs to be paid upfront, as per the Australian Health Record Regulation.
    7) I need to make a longer appointment if I have more than one issue or complex health conditions.

    Please sign here

    Signed on :