New Patient Intake

Patient Registration Form

Please complete this form prior to your initial consultation with Mr Sam Bewsher. All information provided is kept strictly confidential.

1. Personal Information

Basic contact details for patient records.

Title *

First Name *

Surname *

Preferred Name

Date of Birth *

Street Address *

Suburb / Town *

State *

Postcode *

Phone *

Email *

Emergency Contact / Guardian

Contact Name

Phone

Relationship

Allergies

2. Referral Details

Details of the doctor who referred you, and your regular GP if different.

Referring Doctor *

GP (If Different)

GP Street Address

Suburb / Town

Postcode

Attach Referral Letter / Scan Images (Optional)

Accepted formats: PDF, JPG, PNG up to 10MB each.

3. Medicare & Insurance Details

Required for rebate processing and hospital bookings.

Medicare Card No.

Ref No.

Expiry

Private Health Insurance Fund

Level (if known)

Membership No.

Ref.

DVA No.

Card Colour

TAC / WorkCover No.

Insurer

4. Fee Policy, Privacy & Declaration

Please read carefully and consent to proceed with submission.

Mr Bewsher's consulting fee policy is on display at the reception desk and is available electronically upon request.

Privacy Notice Personal and medical information collected by Mr Bewsher is used and stored in accordance with the Privacy Act 1988 and the Privacy Amendment (Enhancing Privacy Protection) Act 2012. The Australian Privacy Principles (APP) require that informed consent be obtained before or as soon as practical after personal information is collected. Your information may be shared with other providers (such as radiology clinics, pathology laboratories, other specialists, your GP or referring doctor), as in order to provide you the best medical care, all members of the team must be informed to the degree necessary for them to do this. Your information, x-rays and clinical photos may be used for the secondary purposes of surgical audit and clinical research. Your privacy is strictly maintained by de-identifying results if they are shared amongst other health professionals for audit, education or research purposes. Mr Bewsher will use an AI note taking tool during your consultation to assist with accurate documentation. You are entitled to request a copy of your records. The full privacy policy is available electronically on request.

Full Name (in lieu of signature) *

Date *

I, hereby in lieu of my signature, understand Mr Bewsher's consulting fee policy, and consent to my information being collected and used as outlined above.