New Patient Registration

Personal Details

Title

First Name(s)

Surname

Date of Birth

Pronouns

Contact Details

Home Phone

Mobile Number

Email Address

Residential Address

Suburb

Postcode

Medicare & Healthcare Details

Medicare Number

Reference Number

Expiry Date

Department of Veterans' Affairs (DVA)

Gold Card White Card Blue Card Not Applicable

Private Health Insurance

Do you have private health insurance with hospital cover?

Yes No

If Yes:

Health Fund Name

Membership Number

Referring Doctor Details Usual GP

Medical Practice Name

Emergency Contact / Next of Kin

Next of Kin Name

Relationship to Patient

Contact Number

Parent / Guardian Details

(Complete only if the patient is under 18 years of age)

Parent / Guardian Name

Date of Birth

Address

Postcode

Medicare Details (Parent / Guardian)

Medicare Number

Reference Number

Expiry Date

Referral Upload

Please upload your GP or Specialist referral if available.

Do you consent to the following?

Receive SMS text messages from MRSS

Yes No

Receive Emails from MRSS

Yes No

Clinician use of AI transcription software for notes and letter writing

Yes No

Some MRSS clinicians utilise secure AI-assisted clinical documentation technology during consultations to support accurate record keeping and the preparation of consultation notes and correspondence. This technology helps clinicians create comprehensive clinical documentation while maintaining their focus on patient care. No audio recordings are retained, and all information is managed in accordance with the MRSS Privacy Policy and applicable Australian privacy and healthcare regulations. If you have any questions or concerns regarding the use of this technology, please speak with your specialist or a member of the MRSS team.

Fees, Cancellations & Privacy Policy Acknowledgement

View Privacy Statement

I acknowledge I have read and understood the MRSS consultation fees and cancellation policy

I acknowledge I agree with the MRSS privacy policy

How were you referred to MRSS?

Contact Info:

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