Patient Registration – Chatswood ENT

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New Patient Registration

Which clinic location is this registration for?

Please select the appropriate clinic logo below to proceed.

Clinic *

Chatswood ENT
Mid North Coast ENT at Kempsey

Billing Details

Account Type *

Medicare details (Parent / Carer / Guardian)

Medicare Card Number (if different from patient)

Only required if different from patient’s card

Parent / Carer / Guardian Ref Number on Card (IRN) *

💡
Note: Required only if you are financially responsible for this account. Enter your individual reference number (1–9), or enter 0 if this does not apply.

Medical Reports & Investigations

Please upload any background clinical information prior to the appointment. Reviewing these documents beforehand ensures the patient is matched with the most appropriate specialist for their specific symptoms:

Clinical & Specialist Reports: Non-GP specialist correspondence (e.g. Paediatricians, Respiratory Physicians, Neurologists), speech pathology, or allied health reports.
Imaging & Diagnostic Scans: Radiology reports, CT scans, MRIs, X-rays, or audiograms.
Test Results & Health Studies: Pathology results or sleep studies.
Upload Instructions: Drag & drop files, select Choose Files to Upload, or tap Capture With Camera to take a photo. Accepts PDF, JPG, PNG, or HEIC (up to 4 files, 15MB total).

💡 Maximising Consultation Value: Providing complete records allows our team to confirm correct sub-specialty allocation, tailor treatment options, and avoid unnecessary follow-up visits or redirection to a different specialist.

Upload Reports & Scans (Optional):

Additional Relevant Medical Reports & Investigations

Drag & Drop Files, Choose Files to Upload, or Capture With Your Camera You can upload up to 4 files.

Primary Symptoms & Reason for Referral

Please describe the primary medical concerns or symptoms prompting this consultation:

Main Symptoms: Outline key symptoms, onset, and duration (e.g. nasal blockage, chronic sinusitis, recurrent epistaxis, snoring/sleep issues, recurrent tonsillitis, or ear infections/hearing loss).

Impact & Severity: Note any factors that worsen or relieve the symptoms, or how they affect breathing, sleep, school, or daily activities.

💡 Why We Ask for Personal & Clinical Context: Doctor referral letters provide essential medical background, while firsthand observations from the patient, parent, or carer offer vital complementary details. Sharing how symptoms affect daily life gives our clinical team a broader understanding of the condition, ensuring the appointment is scheduled with the ENT surgeon best suited to their specific needs.

Symptom Details & Additional Notes:

Primary Symptom(s) & Additional Clinical Notes (Free Text)

Patient Height and Weight

Height (cm) *

Weight (kg) *

Accuracy of Measurements *

Recent and Accurate
These measurements were taken accurately within the last 6 months.
Estimated or Approximate
These measurements are based on an estimate rather than a physical measurement.
Unsure / Outdated
These measurements were taken over 6 months ago or require clinic verification.

Why We Ask for Height & Weight

Height and weight provide our clinical team with essential context regarding the patient’s overall health, physical development, and growth trajectory. Capturing these measurements ensures:

Tailored Dosing: Accurate calculation of medication dosages whenever prescriptions or medical treatments are required.
Treatment & Surgical Readiness: Crucial physiological data for safe procedural and anaesthetic planning should surgical options be discussed.

Additional Recipients for Clinical Letters

The referring practitioner automatically receives copies of all consultation notes and correspondence. If you would like copies sent to other health professionals involved in the patient’s care, please specify them below:

Medical Specialists: Paediatricians, Respiratory Physicians, Neurologists, or Surgeons.
Allied Health Practitioners: Audiologists, Speech Pathologists, or Occupational Therapists.
Other Health Services: Secondary GPs, Family Medical Centres, or Care Coordinators.

💡 Please Note: Many practitioners consult across multiple clinics and hospitals. Providing their full name, clinic or hospital name, and suburb ensures that reports arrive at the expected location without delay.

Additional Practitioner & Clinic Details (Optional):

Send copies of clinical correspondence to additional health providers?

Consents, Privacy & Billing Terms

Consent to Collect Health Information

Privacy Act 1988 • Australian Privacy Principles

Chatswood ENT collects personal and health information to provide high-quality medical care. The patient’s health information is used for:

Administrative operations and the ongoing clinical management of our practice.
Billing, Medicare, and Services Australia compliance requirements.
Disclosure to treating doctors, referring specialists, and diagnostic service providers (e.g. pathology, radiology).

💡 Access Rights: The patient or their authorised representative has the right to request access to collected health information in accordance with Australian privacy laws.

Consent for Handling Health & Personal Information *

I Agree

Consent for Clinical AI Documentation & Dictation

Privacy Act 1988 • Australian Privacy Principles • Secure On-Shore Data Processing

To ensure our surgeons can devote their full visual and conversational attention to the consultation rather than typing on a computer, our practice utilises secure ambient AI technology (Heidi Health) to assist in generating clinical notes and dictating doctor correspondence.

Purpose: Summarises the clinical conversation in real-time to generate accurate medical records, treatment plans, and referral response letters.
Data Storage & Sovereignty: All information is encrypted end-to-end and hosted exclusively on secure Australian servers (AWS Sydney).
Privacy & Deletion: Audio recordings are processed securely to create written notes and are automatically deleted after processing. Audio is never stored permanently, nor is data used to train AI models.
Clinical Review: All AI-generated clinical summaries are thoroughly reviewed, verified, and approved by the treating ENT surgeon prior to finalising.

🔒 Your Choice: Use of ambient AI is completely voluntary. Patients or carers may request to opt out at any point prior to or during the consultation without affecting the quality of care provided.

Consent to Ambient AI Documentation *

Limitations, Court Orders & Disclosure Restrictions (Free Text)

Limitations, Court Orders & Disclosure Restrictions

Please outline any specific legal arrangements, privacy requests, or safety considerations for our practice to note:

Court Orders & Parenting Plans: Family Court orders, parenting agreements, or protection orders (such as Apprehended Violence Orders / AVOs) restricting contact or access to medical records.
Disclosure Restrictions: Requests not to share medical details with specific individuals, family members, or organisations (where permitted by law).
Correspondence Limits: Requests to withhold specific sensitive information from referring doctor letters or automated appointment reminders.

⚠️ Important Legal Note: Mandatory legal obligations, clinical safety requirements, emergency care, and Medicare reporting must still be upheld by law. Please provide copies of any relevant court orders to our practice as early as possible prior to the consultation.

Additional Legal or Privacy Notes (Optional):

Authorised Communication Channels & Preferences *

To ensure smooth care coordination, our practice uses the following three channels by default for timely clinical, financial, and appointment updates:

SMS / Mobile Text: Appointment confirmations, reminder notifications, eScript tokens, waitlist offers, and urgent clinical alerts.
Email Correspondence: Formal appointment letters, pre- & post-operative care guides, pathology/imaging requests, fee estimates, and accounts.
Telephone Calls: Direct phone communication from practice staff, clinical nurses, or treating surgeons regarding care or results.

⏳ Respecting Everyone’s Time & Access to Care: Timely SMS and email confirmations ensure our surgeons’ clinical hours are fully utilised and allow us to offer earlier appointments to patients on our cancellation waitlist.

💡 Preferences & Opt-Outs: All channels below are selected by default.

Please uncheck any channel you prefer our practice not to use for routine updates.

Preferred Methods of Contact *

SMS / Text Messages
Email
Telephone

Financial consent

Financial Terms & Payment Policy

This clinic operates as a private specialist practice. Please review our financial terms regarding consultations and accounts below:

Day-of-Service Fees: Consultation fees are payable on the day. While most minor procedures (such as scopes, earwax removal, biopsies, and cautery) are bulk-billed as a courtesy, a valid Medicare referral is strictly required. If your referral is missing or expired when these procedures are performed, private billing rates will apply.
Medicare Rebates: Medicare claims can be processed electronically on the day for direct rebate payment into your nominated bank account.
Financial Responsibility: The patient or nominated parent/carer remains fully responsible for settling all fees incurred.
DVA, ADF & Third-Party Funding: Where official pre-approval, ADF Garrison Health authorisation, or eligible DVA coverage is not confirmed prior to your visit, standard private consultation fees will apply on the day.

💳 Payment Methods: We accept EFTPOS, Visa, Mastercard, American Express, and cash (correct change is appreciated).

Financial Policy & Payment Terms *

I Agree

Patient / Representative Declaration

By signing below, I certify that all information provided in this registration form is complete and accurate to the best of my knowledge, and I agree to the consent, privacy, and financial terms outlined above.

Full Name of Person Completing Registration *

Date

Digital Signature & Declaration

By providing a signature below, the individual completing this registration confirms that all details provided across this form are accurate, true, and correct to the best of their knowledge.

✍️ How to Sign: Use a touchscreen (finger or stylus), trackpad, or mouse cursor directly inside the box below to draw a digital signature. If an error is made, click the Clear button to reset the field.

Signature of Person Completing Registration *

Clear Signature

Form Review & Submission

Before submitting, please review your entries to ensure all details provided are complete and accurate.

💡 Form Navigation: You can safely use the Previous button below to navigate back through any section of this form—all entered information will remain saved. Click Submit Registration once complete.

New Patient Registration

Which clinic location is this registration for?

Who is completing this registration form?

Patient Demographics

Parent / Carer Demographics

Billing Details

Medicare Details (Patient)

Medicare details (Parent / Carer / Guardian)

Private Health Insurance Details

Third-Party Claims

ADF

DVA

DVA White Card Details

DVA Orange Card details

Overseas Health Cover (OVHC / OSHC)

Referral, Health Care Team and Clinical Details

Patient Height and Weight

Communication Roles & Authorised Contacts

Carer & Representative Registration

Consents, Privacy & Billing Terms

Financial consent

Chatswood ENT

Dr Bill Johnston

Associate Professor Raewyn Campbell

Qualified Practitioner Diagnostic Audiology

Address

The Gallery
Level 1, 445 Victoria Ave
Chatswood NSW 2067

Find

Contact

02 9188 9292
referral@chatswoodent.com.au
Healthlink: chatsent
fax: 02 9188 1611

Email

New Patient Registration

Which clinic location is this registration for?

Who is completing this registration form?

Patient Demographics

Parent / Carer Demographics

Billing Details

Medicare Details (Patient)

Medicare details (Parent / Carer / Guardian)

Private Health Insurance Details

Third-Party Claims

ADF

DVA

DVA White Card Details

DVA Orange Card details

Overseas Health Cover (OVHC / OSHC)

Referral, Health Care Team and Clinical Details

Patient Height and Weight

Communication Roles & Authorised Contacts

Carer & Representative Registration

Consents, Privacy & Billing Terms

Financial consent

Chatswood ENT

Dr Bill Johnston

Associate Professor Raewyn Campbell

Qualified Practitioner Diagnostic Audiology

Address

The Gallery Level 1, 445 Victoria Ave Chatswood NSW 2067

Find

Contact

02 9188 9292 referral@chatswoodent.com.au Healthlink: chatsent fax: 02 9188 1611

Email

The Gallery
Level 1, 445 Victoria Ave
Chatswood NSW 2067

02 9188 9292
referral@chatswoodent.com.au
Healthlink: chatsent
fax: 02 9188 1611