Patient Information

Dr Wood sees adult female and male patients over the age of 18 years.

Please bring a valid referral letter from a doctor and any relevant test results they have ordered.

At the time of booking an initial consultation, Dr Wood requires a non-refundable partial prepayment of $100. This will go towards the cost of your appointment upon attendance. Missed appointments take valuable time away from others, and as such a prepayment is required to reduce the chance of non attendance.

We accept EFTPOS, Visa and Mastercard credit cards and cash payments.

You will need your Medicare card in order to process a claim. Your claim will be automatically lodged with Medicare and the rebate will appear in your account usually within 24 hours.

Please only complete the new patient registration form after you have called to make an appointment.

New Patient Registration - Dr Rebecca Wood

Select

Name

First Name

Last Name

Preferred Name

(If different to above)

Date of Birth

Gender

Male

Female

Unspecified

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Postal Address

(If different):

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (Home)

Phone (Mobile)

Medicare

Medicare Number

Reference Number

Number in front of your name on the card

Expiry Date

DVA Card Number

(If applicable)

DVA Card Type

(If applicable)

White

Gold

Emergency Contact

Name

First Name

Last Name

Relationship

Phone (Home)

Phone (Mobile)

GP Details

If different to your referring doctor

GP Name

Name of your GP

First Name

Last Name

GP Address

Address of your usual GP

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Psychologist

If you have one and wish to have correspondence sent to them as well

Psychologist Name

Name of your Psychologist

First Name

Last Name

Psychologist Address

Address of your Psychologist

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Antenatal & Postnatal Patients Only

Names & Ages of Children

Privacy Information and Consent - (Privacy Act 1988 (Cth) and HRIP Act 2002 (NSW))

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assist, diagnose and treat illnesses and be pro-active in your health care. We will also use the information you provide in the following ways: • Administrative purposes in running our medical practice • Billing purposes, including compliance with Medicare and HIC requirements • Disclosure to others involved in your health care, including doctors and specialists outside of this medical practice • Disclosure for research and quality assurance activities I have read the information above and understand the reasons why my information must be collected. I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me. I am also aware that this practice has a privacy policy which contains information about accessing and seeking correction of personal information and privacy complaints handling process. This privacy policy is accessible at www.drrebeccawood.com.au. I am aware of my right to access the information collected about me, except in circumstances where access might be legitimately withheld with an explanation provided. I understand that if I request access to information about me, the practice will be entitled to charge fees to cover time and administrative costs. In accordance with State and Federal Privacy Legislation, I hereby consent to my information being collected and released, if necessary, to assist in my continuing care and treatment. By clicking the SEND button below, I agree to this and electronically sign. If under 16 years of age, this form must be completed by a parent/guardian.

Cancellation and No Show Policy Information and Consent

We understand that situations arise in which you must cancel or reschedule your appointment. We respectfully request that you provide us with more than 48 hours notice if you need to cancel or reschedule. This will give the possibility for another person, who is waiting for an appointment, to be scheduled in your place. All appointments will be prepaid on the Friday before the appointment, by credit card details held securely. Appointments which are cancelled with less than 48 hours notification will not be refunded. This fee is not eligible for a medicare rebate. An invoice will be sent to you for this fee and this must be paid in full prior to, or at your next appointment if not prepaid. Patients who have a “no-show” twice in a 12 month period, or who cancel with inadequate notice twice in a 12 month period, will not be given priority for future appointments. By clicking the SEND button below, I agree to this and electronically sign. If under 16 years of age, this form must be completed by a parent/guardian.

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