ECS Ref - Dr Bos

Patient Registration Form

ECS

Once you’ve completed this form, you’ll be redirected to the Bosman Clinic website. There you can book an appointment and find more information about our clinic, consultation fees, and answers to frequently asked questions.

PATIENT DETAILS

First Name

Last Name

Date of Birth

Mobile Phone

Email

Address

City / Suburb

Postcode

State

English is a Second Language

YesNo

Gender

MaleFemaleNon-binaryPrefer not to say

ATSI

AboriginalTorres Strait IslanderNone of the Above

Ethnicity

MEDICARE DETAILS

Medicare or IHI details are required to issue e-prescriptions. If left blank, we’ll need to request this information before prescriptions can be provided.

Medicare First & Last Name *Please ensure your full name matches your Medicare details.

Medicare Card No. *If you don’t have a Medicare number, please enter 10 zeros (0000000000), and our team will be in touch to assist you.

Cardholder Position

Expiry

IHI No.Please provide your IHI number if you do not have medicare.

EMERGENCY CONTACT DETAILS

Name

Mobile Phone

Email

REGULAR DOCTOR DETAILS

Regular Doctor’s Name *

Regular Doctor Practice Name *

Address

PENSION/HCC/DVA Card

Do you have an aged pension card, healthcare card or a DVA card

YesNo

HEALTH SUMMARY

Health Summary Consent – Authorisation for Use and Disclosure of Information

I consent to the release of my health care records in the form of a Health Summary, which may include (where applicable) details of my medical history, current and previous medications, and any relevant clinical notes, comments, or concerns regarding my health.

I authorise the release of this information to the Bosman Clinic for the purpose of ongoing medical care. This information may be sent electronically to info@bosmanclinic.com.

I also consent to the Bosman Clinic preparing and forwarding treatment update letters to my regular and/or referring General Practitioner to support coordinated care.

*

Were you referred by ECS? *

YesNo

SUPPORTING DOCUMENTATION (Optional but Recommended)

To help Dr Bosman prepare for your appointment and provide the most appropriate care, you’re welcome to upload any relevant supporting documents here.

These documents are not mandatory, but they can be very helpful in giving context to your medical history and current treatments.

Examples of supporting documents you may wish to upload include (but are not limited to):

Referral letters
Clinic discharge letters
Recent GP or specialist letters
Health summaries or care plans
Pathology or blood test results
Imaging reports (e.g. X-ray, MRI, CT, ultrasound reports)
Previous scripts

Please upload any documents you feel may be relevant to your upcoming appointment.

Upload documentation here

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SIGNATURE

I declare all answers provided herein are true and accurate to the best of my knowledge and belief. *

Patient/ Guardian Signature *

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Today's Date

Important: Consultation with a Doctor does NOT guarantee prescriptions for medicinal cannabis medications. As per the Therapeutic Administration Guidelines, this treatment option isa second-line treatment modality where all othertreatments have failed. Provision of prescriptions is at your treating Doctor's discretion.

Updated New Patient Form

Important: Completion of this form does not reflect anyappointment bookings. Once your form is received by our team, you will be redirected to an appointment scheduling and payment processing page. Should you have any questions, please contact us directly at info@bosmanclinic.com.

Bosman Clinic is not an Emergency Service and if immediate treatment is required you should contact the nearest Emergency Department orcall 000.

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