VPSC Patient Registration Form Child's Name * First Name Last Name Known as: (Nickname) Date of Birth * MM DD YYYY Current Age * Aboriginal & Torres Straight Islander Status Yes No Child's Residential Address/s: Address 1 Address 2 City State/Province Zip/Postal Code Country Mother/Guardian's Full Name: * First Name Last Name Date of Birth (required for online claiming) MM DD YYYY Mobile Phone * (###) ### #### Email * Occupation: Work Phone: (###) ### #### Residential Address: (if different from child) Address 1 Address 2 City State/Province Zip/Postal Code Country Father/Guardian's Full Name: First Name Last Name Date of Birth * (required for online claiming) MM DD YYYY Mobile Phone (###) ### #### Email Occupation: Work Phone: (###) ### #### Residential Address: (If different from child) Address 1 Address 2 City State/Province Zip/Postal Code Country Would you like an SMS reminder of your child's appointment ? * Yes No If yes (please choose one option) Mother's Mobile Father's Mobile Do you have Private Health Insurance? * Yes No Name of Private Fund Membership Number Medicare Number * Medicare Expiry Date MM DD YYYY Child's Reference No. Mother's Reference No. Father's Reference No. REFERRAL * Name of referring General Practitioner / Specialist Date of Referral MM DD YYYY Personal Medical Information Authorisation * I UNDERSTAND THAT THIS PRACTICE HANDLES PERSONAL INFORMATION IN ACCORDANCE WITH THE NATIONAL PRIVACY PRINCIPLES ENSHRINED IN THE PRIVACY ACT 1988 (COMMONWEALTH) AND AS OUTLINED IN THE PRIVACY STATEMENT. I CONSENT TO THE HANDLING OF MY INFORMATION BY THIS PRACTICE FOR THE PURPOSE OF PROVIDING QUALITY HEALTH CARE, ASSOCIATED ADMINISTRATIVE AND BILLING PURPOSES, AND DISCLOSURE FOR RESEARCH AND QUALITY ASSURANCE ACTIVITIES. I ALSO GIVE PERMISSION FOR MEDICAL INFORMATION TO BE OBTAINED FROM ANY OTHER SOURCE IN ORDER TO HELP WITH MY TREATMENT YES I do authorise NO I do not authorise Thank you!Please email your referral to: reception@visc.health
