Registration Form

Title *

Content

PATIENT INFORMATION

Title *

Name *

Surname *

Date of birth *

Marital Status *

Residential Address

City

Postcode

Are you interstate or overseas visitor to Sydney?

Null
YES
NO

CONTACT DETAILS

Home Phone *

Mobile Phone *

Work Phone *

Email *

NEXT OF KIN / EMERGENCY CONTACT

Name *

Relationship to Patient

Home Phone *

Mobile Phone *

Work Phone *

MEDICARE AND HEALTH INSURANCE

Medicare Card Number *

Reference Number

Expiry Date

Do you have Private health cover?

Null
YES
NO

Name of Health Fund

Membership Number

Level of Cover

Null
Basic
Intermediate
Top

Have you been in the fund more than 12 months

Null
YES
NO

If you have an excess, please list

AREAS OF INTEREST / CONCERN

Interest

Other

MEDICAL HISTORY

Do you have any history of the following:

(please tick all applicable)

Other Medical Condition

Please list here

Could you be or are you pregnant?

Null
YES
NO

Please list all current medications (including over the counter medications, vitamins and minerals)

Have you been admitted to hospital in the last 12 months?

Null
YES
NO

More info about admitted to hospital

Have you had any previous surgical procedures?

Null
YES
NO

More info about previous surgical procedures

Please list any known allergies

TOBACCO HISTORY

Tobaco History

Null
I have never smoked
Previous smoker
I smoke

Cigarettes

per day / week

Day
Week

ALCOHOL INTAKE

Alcohol Intake

Null
I do not drink alcohol
I drink

standard drinks

per day / week

Day
Week

REFERRED TO CLINIC / PRACTICE BY

Referred by

Referrer Name

FEE STRUCTURE

Rhinoplasty consultation $440.
Injectable Rhinoplasty consultation $250 – $440 (depending on tests performed by Dr Mooney).
Cosmetic consultation $250 + treatment performed (if required).
ENT and other consultation $250 + treatment performed (if required).
Follow up consultation $120 + treatment performed (if required).
Patients who have had surgery with Dr Mooney and require a follow up consultation outside of their surgical post operative period of 6 months or 12 months (rhinoplasty patients only) will be required to pay a consultation fee $120 + tests and / or procedures on the day.
Any consultations booked with Dr Mooney after a 12 month period will require a new referral and will be charged $250 + test and / or procedures on the day.

Please note: Medicare state that all patients must have a valid referral on file at all times.

Information is True *

The above information is true to the best of my knowledge. I am aware of practice fees and understand that I am financially responsible unless advised otherwise by our reception staff.

Give Permission