Patient Registration - Medical Synergy Group

PATIENT REGISTRATION INFORMATION REQUIRED

Your options to providing your information are:

Title
- Mr
- Mrs
- Miss
- Ms
Name*
Given Name Middle Initial Family Name
Preferred Name
Date of Birth*
Date Format: DD slash MM slash YYYY
Street Address*
Address Town / Suburb Postcode
Mobile Phone*
Home Phone
Work Phone
Email*
Medicare Number*
Expiry Date*
Concession Card Number
Expiry Date
General Practitioner
Employer
Insurance Company
Claim Number
Case Manager
Date of accident/injury
Date Format: DD slash MM slash YYYY
Driver's Licence Number
Consent
I consent to MSG Health recording and sharing information obtained from me. I understand that this may be shared with laboratories, radiological facilities, other health service providers, rehabilitation consultants, insurers, medical defence organisations, lawyers or my employer for the purpose of investigation, treatment and rehabilitation of my injury or illness.

I also agree that if my injury is "claim related" and the claim is not accepted I will be responsible for all costs involved for Doctor, Nurse and Physiotherapy treatments.
Patient Signature*
Phone
This field is for validation purposes and should be left unchanged.