Patient Registration Form

Click here to download the printable version

Fill all required fields (★) to submit the form.

Full Name:(Required)

Preferred name:

Date of birth:(Required)

Mobile Number:(Required)

Home Phone:

Address:

Email Address:(Required)

Responsible Party:(Required)

Membership/Claim number:

Contact number:

Address:

Email address:

Next of Kin:

Name:

Address:

Contact number:

Relationship to patient:

Emergency contact:

Insurance Information:

Medicare number:

Your Ref no:

Name of Private Health Fund:

Expiry Date

Member Number:

Referrals:

General Practitioner:(Required)

Referring Doctor:

RSDC doctors would like all the referrals to be sent no later than one day prior to the scheduled appointment. Specialist referrals are valid for 3 months and GP to specialist referrals are valid for 12 months. We recommend obtaining a a referral from your GP that will last for one year.

Information about Fees:

RSDC doctors do not bulk bill in their private rooms, however they do attend public clinics which will require a valid referral.
Payment in full is required on the day of the consultation.
For the details of RSDC fees please call our staff 1300773210.
There is an out-of-pocket cost for the Cardio Pulmonary Exercise Test and Home-Based Sleep Study for all patients.

Payment and Cancellation Policy:

In the event an appointment is cancelled with less than one business day notice, full consultation fee will be charged.

Dr Ali Aminazad

Dr Timothy Cheung

Dr Chuan Foo

Dr Shahab Makki

Dr Sadie Porsa

Health Professionals

Patients

FAQ

Publications

Gp Education Events

Appointment Request Form

Lung Function Request Form

Home-Based Sleep Study Request Form

Medical Review Referral Form