Pre-register

If you are a new patient due to see Dr Balalla, you can fill in your registration information via the form below.

If you prefer please download the form, print and bring it filled for your appointment.

Download form

Patient Information Sheet Dr Buddhika Balalla

Title
First Name
Last Name
Date of Birth
Email
Home Phone
Work Phone
Mobile Phone
Address
Suburb
Postcode
State
Medicare Number
Reference on Card
Expiry Date
Private Health Fund
Membership No.
Ref
Health Care/Pension/DVA Card Number
Type
- Aged Pension
- DVA
- Other
Referring Doctor
Type
- Specialist
- GP
Usual GP (If different from above)
Usual GP Phone No.
Are there other medical practitioners you would like correspondence to be sent to apart from your referring doctor and usual GP?
- Yes
- No
Name
Address
Phone
Consent to collect patient information
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 medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in the following ways:
1. Administrative purposes in running our medical practice.
2. Billing purposes, including compliance with Medicare and Health Insurance Comission requirements.
3. Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you.
- I 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 understand that if my information is to be used for any purpose other than the above, my consent will be sought.
- I consent the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.
Patient's Name
Date
MM slash DD slash YYYY
Work Cover or Third Party Insurance Claims
Insurance Company
Claim Number
Case Manager
Phone Number
Employer
Contact
Phone Number
Address

Pre-register

If you are a new patient due to see Dr Balalla, you can fill in your registration information via the form below.

Patient Information Sheet Dr Buddhika Balalla

Consent to collect patient information

Work Cover or Third Party Insurance Claims