Contact Us

Phone
(03) 9805 4305

Email
manager@catocardiology.com.au

Online Enquiry

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On-line Patient Registration Form

Title
Surname *
First Name *
Date of Bith *
Address *
Contact Number *
Occupation *
Email *
Next of Kin
Name *
Relationship *
Next of kin contact number *
General Practitioner Details (If not referring doctor)
Name of Practitioner
Address of Practitioner
Post Code
Billing Details
Medicare Number *
Expiry Date *
Reference *
Pension Card/ Government Healthcare Card number
Expiry Date of Pension Card/ Government Healthcare Card number
Veterans' Card Number (Gold Card Only)
Private Health Insurance
Membership Number
Do you consent to being contacted by SMS?
Yes
No
Do you consent to being contacted by Email?
Yes
No
Privacy Agreement

Cato Cardiology collects and holds personal health information about you so that we can properly assess, diagnose and treat. It is sometimes necessary to disclose information about you to other health care providers. At times it is also necessary for us to obtain information about you from other medical practitioners (or the like) in the form of previous correspondence and/or test results in relation to your health. We require your consent for this. Please ask us if you wish to discuss this further. By signing this form I also agree to pay all costs associated with my consultation and understand that failure to do so may result in my invoice being sent to a debt collection agency for recovery and extra fees will be incurred and paid for by me.

Type your Full Name if you Agree to the Terms Above *
Todays Date *
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