Pre-admission form - Pindara Day Procedure Centre

Pindara Day Procedure Centre

Date of Procedure:*
Procedure/Item Number/s:
Doctor:*
Title*
- Mr
- Mrs
- Miss
- Ms
- Dr
First Name:*
Last Name:*
Email*
Address*
Mob Ph Number:*
Medicare Number:*
Ref No:*
Expiry:*
Gender:*
- Male
- Female
Date of Birth*
Country of Birth*
Marital Status*
- Single
- Married
- De Facto
- Widowed
- Divorced
Employment Status:*
- Employed
- unemployed
- retired
- other
Uninsured*
- Yes
- No
Health Fund Details:
Fund Name:*
No:*
Excess?
PERSON RESPONSIBLE / NEXT OF KIN DETAILS
Title*
- Mr
- Mrs
- Miss
- Ms
- Dr
Name*
Relationship to Pt:*
Address:*
Mob Ph Number:*
The hospital fee/excess to be paid on or BEFORE admission either by:
- Direct Debit: BSB 064 214 Account No 1004 3340
  (Use your Surname as the Reference), please retain a copy of your payment and bring to your appointment
- EFTPOS/Visa/Mastercard - WE DO NOT ACCEPT CASH
Patients need to contact their Health Fund prior to admission