Patient Registration Form

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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:

Member Number:

Referrals:

General Practitioner:(Required)

Referring Doctor:

A valid referral outlining the procedures you wish to discuss is required before your consultation. If you haven’t already provided your referral, please send it at your earliest convenience.
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 two business days notice, full consultation fee will be charged.