Patient Registration Child

Location Details

Location*

Referral Information

Who is your doctor?

Your Doctor

How did you hear about us?*

Personal Details

Name*

Date of Birth**

Parent/Guardians Name*

Email*

Mobile Phone*

Home Phone*

Address*

State*

Occupation

Do you consent to your report being sent to your doctor?*

Consent*

Yes

How would you like to receive your report?*

Report*

Post

Do you want to receive the newsletter three times a year?*

Newsletter*

Yes, by email

Yes, by post

Is the patient on a pension card or health care card?*

Pension Card*

Yes

Pension or Healthcare Number:

P.Card No.

Patient Medicare Number

Medicare Number*

Hearing & Ear Health History (Child)

Does your child have a history of:

All questions are required to be answered

Family History of Hearing Loss*

Yes

Ear Infections*

Yes

Ear Surgery*

Yes

Do you have any concerns about your child's speech and language development?*

Yes

Did your child pass the hearing test in hospital after birth?*

Yes

Do you have any concerns about your child's academic progress?*

Yes

If required, do you consent to wax removal using microsuction and/or curettage?*

Yes

Known Allergies

Attach Your Referral (If available)

Drop files here or

Max. file size: 128 MB, Max. files: 3.

Please attach a referral.

Disclosure Statement

Helix Hearing Audiology is proud to provide audiology services in the following:

Audiology Australia and Independent Audiologists Australia’s Code of Conduct, Code of Ethics and Professional Practice Standards.
Hearing Services Program (HSP) best practice principles.
Helix Hearing Audiology is an independent and privately-owned audiology clinic and does not have any obligations to or specific sales targets with any one manufacturer.
Helix Hearing Audiology staff members do not receive any commission nor devices fitted nor do they have any sales targets.
Helix Hearing Audiology may access discounts from any or all manufacturers, including Phonak, Unitron, Widex, Starkey, ReSound, Oticon, Sonic Innovations, Bernafon & Signia, to provide competitive pricing to our patients.

Patient Agreement

Helix Hearing Audiology Staff Conduct

At all times the staff at Helix Hearing Audiology will work to their utmost to provide you with the very best in hearing health care. Should you have any concerns with their conduct at any times we encourage you to discuss this with management.

Patient Conduct

The staff at Helix Hearing Audiology deserve to work in a safe, rewarding and respectful environment. Disrespectful and/or threatening behaviour will not be tolerated. Should this occur you will be asked to leave the clinic immediately. All subsequent communication will be with management only.

Payment of Services

Unless prior arrangements have been pre-approved with management all accounts are to be settled on the day of service, including hearing aid fitting.

Private Health Insurance

HICAPS is not available for audiological services or hearing aids. However, all information required for claims to be made with your private health insurer is available on your receipt. Entitlements are to be claimed directly with your insurer.

Overdue Accounts

All accounts not paid for on the day of service will incur a $10 administration fee. If the account is not paid in full after the second reminder the account will be forwarded to a third-party debt collection agency.

Missed or Rescheduled Appointments

We request 24 hours’ notice to cancel or reschedule an appointment. This is to allow Helix Hearing Audiology time to fill the time otherwise allocated for your appointment. If you fail to give notice, a missed appointment/late cancellation fee may be applied. If this occurs more than once allappointments will be required to be pre-paid. Should pre-paid appointments be missed a refund will not be provided.

Acknowledgement

I confirm that I have read and agree with the terms and conditions above from the date this form is submitted.

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Patient Registration (Child)

Patient Registration Form - Child