Sleep Disorder

Forms

Patient Registration Form

FORMS

Fill all required fields (★) to submit the form.

Full Name:(Required)

Prefix First Last

Preferred name:

Date of birth:(Required)

DD slash MM slash YYYY

Mobile Number:(Required)

Home Phone:

Address:

Email Address:(Required)

Responsible Party:(Required)

DVA (Gold/White)

Aged Pension

Workcover

TAC

N/A

Membership/Claim number:

Contact number:

Address:

Email address:

Next of Kin:

Name:

Address:

Contact number:

Relationship to patient:

Emergency contact:

Insurance Information:

Medicare number:

Your Ref no:

Name of Private Health Fund:

Expiry Date

Member Number:

Referrals:

General Practitioner:(Required)

Referring Doctor:

RSDC doctors would like all the referrals to be sent no later than one day prior to the scheduled appointment. Specialist referrals are valid for 3 months and GP to specialist referrals are valid for 12 months. We recommend obtaining a a referral from your GP that will last for one year.

Information about Fees:

RSDC doctors do not bulk bill in their private rooms, however they do attend public clinics which will require a valid referral.
Payment in full is required on the day of the consultation.
For the details of RSDC fees please call our staff 1300773210.
There is an out-of-pocket cost for the Cardio Pulmonary Exercise Test and Home-Based Sleep Study for all patients.

Payment and Cancellation Policy:

In the event an appointment is cancelled with less than one business day notice, full consultation fee will be charged.

Confirm:(Required)

Please note, if you see one of our doctors and they request a test (bloods, scans, ultrasounds, etc.), the results will be automatically sent to the computer and not seen by the doctors. You will have to make a separate appointment or see your GP for the results if needed.(Required)

Confirm:(Required)

I was informed and agreed to pay the costs associated with the treatment.(Required)

Confirm:(Required)

I have read and accept that I am responsible for having a valid referral and for any consultation fees.(Required)