Somnocare Patient Registration Form

Somnocare Patient Registration Form

Please complete all sections as accurately as possible
Submission Date

DayMonthYear
Personal Information
Date of Birth*

DayMonthYear
Title*
Gender*
First Name*
Middle Name
Last Name*
Age (Days)
Age (Years)
Are you of Aboriginal or Torres Strait Islander origin?*

NoYes, AboriginalYes, Torres Strait IslanderYes, Aboriginal and Torres Strait Islander
Address*

Street Address

Suburb

CityState

Post CodeCountry
Is this also your postal address?*

YesNo
Postal Address

Street Address

Suburb

CityState

Post Code
What is your current Covid-19 vaccination status?*

Double vaccinated plus boosterDouble vaccinated without boosterSingle vaccinationUnvaccinatedOther
Contact Information

Please submit at least one contact number plus your Email address
Mobile Number
Home/Other Number
Work Number
Email address
Next of kin
Relationship to you
Next of kin contact #
Next of kin email address
My next of kin is the person we can contact in the event of an emergency?

YesNo
Name of Emergency Contact
Emergency Contact Phone Number
Relationship to you
I have been referred to this practice by*

I haven't been referred to this practice by a doctorMy GP / Family DoctorA specialist doctor
Type of Specialist
Name of Specialist Doctor
Address or Name of Specialist Doctor's Practice
General Practitioner / Family Doctor
Address or Name of General Practitioner's Practice
Health Cover Information
Medicare Cover*
Medicare Card Number*
Ref #*
Expiry*
Private Insurance*
Health Fund Name*
Card Number*
Cover Type*
Pension Card Holder*
Pension Card Number*
Pension Card Expiry*
DVA Card Holder*
DVA Card Number
DVA Card Type*
Health Care Card*
Health Care Card Number*
HCC Expiry*
Workers Compensation*
Claim Number
Insurance Company
Account Holder*

I am the account holder and will be paying for my medical expenses.My employer or another organisation/person(s) not specified above will be covering my medical expenses. If you have already completed workers compensation information above, please select yourself as the account holder.
Organisation Name
Additional Information
How did you find out about us (optional)
Please specify
Consent
SOMNOCARE PRIVACY POLICY

Somnocare takes all reasonable measures to operate in accordance with the Privacy Act 1988, the Freedom of Information Act 1992 (WA) and the Australia Department of Health guidelines.

These acts and guidelines provide a framework that governs how medical and health services collect and use your personal and health records.

Collection of your information:

We must collect necessary personal and medical information to properly treat you. This information may include, but not be limited to:

Personal and family medical histories
Ethnicity background
Contact details
Medicare and health fund details
Account and billing information

This information will typically be collected directly from you, however Somnocare may also collect related medical records from other health providers who have been, or are currently involved in your holistic healthcare. These may include general practitioners, medical specialists, hospitals or allied health professionals. In the unlikely event you are unable to provide necessary health information (i.e. in emergency situations) we may request information from your nominated next of kin, or other immediate family members (unless, at a prior occasion, you have notified us otherwise).

To read Somnocare's full privacy policies and terms and conditions please click here.

Payments:

Unless a prior arrangment has been made, any payments are to be made in full either before, or on the day of your appointment. Administrative and processing fees may apply to any outstanding accounts over 14 days, while unpaid accounts exceeding 30 days may require debt collection.
Covid-19:

Upon booking a consultation or testing procedure, you will be asked a screening questionnaire addressing recent travel and any active symptoms for Covid-19. Depending on the outcome of this questionnaire, you may not be able to visit our site until circumstances allow. While under Somnocare's care, you are required to notify us immediately if your situation changes, or if you start to experience any cold and flu like symptoms.
I consent to Somnocare using and disclosing my information as outlined in Somnocare's privacy polices, and as outlined in the privacy act and understand that I am required to notify Somnocare if I start to experience any symptoms that could be suggestive of Covid-19.*

YesNo
Note: Without your consent it is unlikely we will be able to proceed with any testing or consultative services. Please contact our rooms to discuss options after submitting this form.
Patient Signature (left click and drag to write your signature)

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Somnocare Patient Registration Form

Personal Information

Contact Information

Health Cover Information

Consent