Patient Registration (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?

    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:

    All questions are required to be answered


    Hearing Loss

    Tinnitus (ringing in ears)

    Balance Problems/Vertigo

    Ear Infections

    Ear Surgery

    Epilepsy

    Diabetes

    Blood Thinning Agents

    Cardiac Pacemaker

    Known Allergies

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

    Disclosure Statement

    Gippsland 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.
    • Gippsland Audiology is an independent and privately-owned audiology clinic and does not have any obligations to or specific sales targets with any one manufacturer.
    • Gippsland Audiology staff members do not receive any commission for devices fitted nor do they have any sales targets.
    • Gippsland 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

    Gippsland Audiology Staff Conduct

    At all times the staff at Gippsland 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 Gippsland 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 Gippsland 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

    We are Gippsland’s only full-time team of local independent audiology experts. Servicing communities in Warragul, Drouin, Bairnsdale, Moe, Newborough, Trafalgar, Morwell Churchill, Traralgon, Rosedale, Sale, Leongatha, Korumburra, Foster & Wonthaggi.


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