Patient Registration

Initial Appointment

An Initial consultation with Dr George Balalis or Dr Jesse Beumer is $280.00. A valid referral is required for this appointment and you will receive a Medicare rebate of approximately $80.85.

Details for your referring doctor

Dr George Balalis or Dr Jesse Beumer Phone: 08 8164 6945 Fax: 08 8490 3283 Email: [email protected], 149 Ward Street, North Adelaide, 5006

Patient Details

Given Names *

Surname *

Preferred Name

Address *

Address Line 1

City

State / Territory

Postcode

D.O.B *

Occupation

Mobile Phone *

Home Phone

Email *

Do you wish to receive email and mobile text messages for appointment and recall reminders *

How did you hear about Dr Balalis or Dr Beumer? Friend, GP, Other specialist, social media (Instagram/Facebook), media print, website or radio? *

To assist with health initiatives, are you Aboriginal or Torres Strait Islander? *

Aboriginal
Torres Strait Islander
Aboriginal & Torres Strait Islander
No

Medical account details

Medicare Card *

Ref *

Expiry

Month *

Year *

If relevant Department of Veteran Affairs (DVA)

DVA Ref

DVA Expiry

Month

Year

Health Care Card / Pension Card

Expiry

Month

Year

Do you have Private Health? *

Do you have top Hospital Gold Cover? (If seeing us to discuss weight loss surgery, you may like to check with your health fund if you are covered for the following item numbers; 31575, 31572, 31585, 31584).

Doctor Details

Do you have a referral? *

Upload your referral (if we haven't received it already)

Click or drag files to this area to upload.You can upload up to 3 files.

Usual GP *

GP practice details *

Other interested parties for medical correspondence

Emergency Contact Details:

First Name *

Surname *

Phone *

Relationship *

Emergency Contact Consent *

In the event of an emergency, I give consent to contact my emergency contact

Consent for medical information *

I give consent to disclose any relevant information regarding my medical conditions
I do NOT consent to disclose any relevant information regarding my medical conditions

Consent for appointment information *

I give consent to disclose any relevant information regarding my appointment information
I do NOT consent to disclose any relevant information regarding my appointment information

What is your primary reason for coming to see our team? *

What are your current medical issues (if any)? *

Have you had any significant medical problems in the past (including any surgeries)? *

If your referral is not from your usual GP, please provide a list of your current medications (including prescription and non prescription medicines, and any supplements or vitamins you take)? *

Do you have any allergies? If yes, please explain your allergy? *

Do you smoke? If yes, how many cigarettes per day? *

Are you an ex smoker? When did you quit? *

Do you drink alcohol? If yes, how many drinks per week/day? *

Privacy *

To enable ongoing care and total quality improvement within this practice and in keeping with the Privacy Act (1988) and the Australian Privacy Principles, we wish to provide you with sufficient information on how your personal and health information may be used or disclosed and record your consent or restrictions to this consent. Your personal and health information will only be used for the purposes for which it was collected, or as otherwise permitted by law and we respect your right to determine how your personal and health information is used or disclosed. The information we collect from you may be collected by a number of different methods and examples may include: medical test results, notes form consultations, Medicare and health insurance details, data collected from observations and conversations with you, and details obtained from other health care providers (e.g. specialist correspondence). By signing below, you (as a patient/guardian) are consenting, that on obtaining your personal and health information it may be used or disclosed by the practice for the following purposes: - for follow up reminder/recall notices for treatment and preventive healthcare; - for accounting procedures and the collection of professional fees; - for the diagnosis and treatment of any health condition, including the communication of relevant information only, to practice staff, specialists and other healthcare providers to ensure quality care is provided; - for the referral (or the onboarding) of you to other health care providers as may be agreed between you and us from time to time, and the subsequent use of your personal and health information by those healthcare providers or the diagnosis or treatment of any health condition; Accreditation and Quality Assurance activities conducted by professionally trained non-treating GPs and other professionally trained and qualified persons, e.g. General Practice Managers; - For legal related disclosures as required by Court of Law; - For the purposes of research where de-identified information is used; - To allow medical students and staff to participate in medical training/teaching using only de- identified information; - For disease notification as required by law; - For use when seeking treatment by other doctors in this practice. At all times, we are required to ensure your details are treated with the utmost confidentiality. We will not discuss medical conditions or appointment information with anyone but the patient (if over 16) without signed consent, this includes spouse and all relatives.

Your Authority *

I understand this document and consent to the above.
I understand that I am not obliged to provide any information requested of me, but failure to disclose correct information may compromise the quality of the treatment and healthcare provided to me.
I certify that the information I have supplied is true and correct information to the best of my knowledge.
I am aware of my right to access information collected about me. I understand that if my information is legitimately withheld, an explanation will be provide.
I am fully responsible for the accounts of services rendered by Dr Balalis, Dr Beumer and those practitioners and specialists consulting in this practice, including any shortfall in reimbursement by Medicare, Healthfunds, Insurance companies and Workers Compensation schemes.
I understand that payment facilities for savings, Visa, MasterCard or cash are accepted. Non-attendance or cancellations of appointments within 48hrs will occur the full intended fee.
I understand that the total fees of specialists for procedures and treatments cannot be absolute but only quoted as a fee estimate in advance.
I understand that if I am uninsured and being treated as an inpatient or day patient in a private hospital, I accept full responsibility for full payment of my account
I have not and will not alter the contents of this or any other form provided by Dr George Balalis, Dr Jesse Beumer & his specialist and allied health team without the practitioners signed agreement.

Patient (Full Name) *

If not the Patient signing – Your full name