Patient Registration Adult

Location Details

Location*

Referral Information

Who is your doctor?

Your Doctor

How did you hear about us?*

Personal Details

Name*

Date of Birth**

Email*

Mobile Phone*

Home Phone*

Address*

State*

Occupation

Do you consent to your report being sent to your doctor?*

Consent*

Yes

How would you like to receive your report?*

Report*

Post

Do you want to receive the newsletter three times a year?*

Newsletter*

Yes, by email

Yes, by post

Is the patient on a pension card or health care card?*

Pension Card*

Pension Card

Health Care Card

Neither

Pension Card Number:

P.Card No.

Is the patient on a DVA card?*

DVA*

White

Gold

What is your DVA Number?

DVA No.

Patient Medicare Number

Medicare Number

Hearing & Ear Health History (Adult)

How would you rate your hearing on a scale of 1 to 10?*
(1 = terrible, 10 = excellent)

Hearing Choice*

Have you ever had or are you suffering from:

All questions are required to be answered

Hearing Loss*

Yes

Tinnitus (ringing in ears)*

Yes

Balance Problems/Vertigo*

Yes

Ear Infections*

Yes

Ear Surgery*

Yes

Epilepsy*

Yes

Diabetes*

Yes

Blood Thinning Agents*

Yes

Cardiac Pacemaker*

Yes

If required, do you consent to wax removal using microsuction and/or curettage?*

Yes

Known Allergies

Attach Your Referral (If available)

Drop files here or

Max. file size: 128 MB, Max. files: 3.

Please attach a referral.

Disclosure Statement

Helix Hearing Audiology is proud to provide audiology services in the following:

Audiology Australia and Independent Audiologists Australia’s Code of Conduct, Code of Ethics and Professional Practice Standards.
Hearing Services Program (HSP) best practice principles.
Helix Hearing Audiology is an independent and privately-owned audiology clinic and does not have any obligations to or specific sales targets with any one manufacturer.
Helix Hearing Audiology staff members do not receive any commission for devices fitted nor do they have any sales targets.
Helix Hearing Audiology may access discounts from any or all manufacturers, including Phonak, Unitron, Widex, Starkey, ReSound, Oticon, Sonic Innovations, Bernafon & Signia, to provide competitive pricing to our patients.

Patient Agreement

Helix Hearing Audiology Staff Conduct

At all times the staff at Helix Hearing Audiology will work to their utmost to provide you with the very best in hearing health care. Should you have any concerns with their conduct at any times we encourage you to discuss this with management.

Patient Conduct

The staff at Helix Hearing Audiology deserve to work in a safe, rewarding and respectful environment. Disrespectful and/or threatening behaviour will not be tolerated. Should this occur you will be asked to leave the clinic immediately. All subsequent communication will be with management only.

Payment of Services

Unless prior arrangements have been pre-approved with management all accounts are to be settled on the day of service, including hearing aid fitting.

Private Health Insurance

HICAPS is not available for audiological services or hearing aids. However, all information required for claims to be made with your private health insurer is available on your receipt. Entitlements are to be claimed directly with your insurer.

Overdue Accounts

All accounts not paid for on the day of service will incur a $10 administration fee. If the account is not paid in full after the second reminder the account will be forwarded to a third-party debt collection agency.

Missed or Rescheduled Appointments

We request 24 hours’ notice to cancel or reschedule an appointment. This is to allow Helix Hearing Audiology time to fill the time otherwise allocated for your appointment. If you fail to give notice, a missed appointment/late cancellation fee may be applied. If this occurs more than once allappointments will be required to be pre-paid. Should pre-paid appointments be missed a refund will not be provided.

Acknowledgement

I confirm that I have read and agree with the terms and conditions above from the date this form is submitted.

CAPTCHA

Patient Registration (Adult)

Patient Registration Form - Adult

Location Details

Referral Information

Who is your doctor?

How did you hear about us?*

Personal Details

Do you consent to your report being sent to your doctor?*

How would you like to receive your report?*

Do you want to receive the newsletter three times a year?*

Is the patient on a pension card or health care card?*

Pension Card Number:

Is the patient on a DVA card?*

What is your DVA Number?

Patient Medicare Number

Hearing & Ear Health History (Adult)

How would you rate your hearing on a scale of 1 to 10?*
(1 = terrible, 10 = excellent)

Have you ever had or are you suffering from:

Disclosure Statement

Patient Agreement

Helix Hearing Audiology Staff Conduct

Patient Conduct

Payment of Services

Private Health Insurance

Overdue Accounts

Missed or Rescheduled Appointments

Acknowledgement

Patient Registration (Adult)

Patient Registration Form - Adult

Location Details

Referral Information

Who is your doctor?

How did you hear about us?*

Personal Details

Do you consent to your report being sent to your doctor?*

How would you like to receive your report?*

Do you want to receive the newsletter three times a year?*

Is the patient on a pension card or health care card?*

Pension Card Number:

Is the patient on a DVA card?*

What is your DVA Number?

Patient Medicare Number

Hearing & Ear Health History (Adult)

How would you rate your hearing on a scale of 1 to 10?*(1 = terrible, 10 = excellent)

Have you ever had or are you suffering from:

Disclosure Statement

Patient Agreement

Helix Hearing Audiology Staff Conduct

Patient Conduct

Payment of Services

Private Health Insurance

Overdue Accounts

Missed or Rescheduled Appointments

Acknowledgement

How would you rate your hearing on a scale of 1 to 10?*
(1 = terrible, 10 = excellent)