• Somnocare Patient Registration Form

    Please complete all sections as accurately as possible
  • Submission Date
     - -

  • Personal Information

  • Date of Birth*
     - -
  • Are you of Aboriginal or Torres Strait Islander origin?*
  • Is this also your postal address?*
  • What is your current Covid-19 vaccination status?*

  • Contact Information

    Please submit at least one contact number plus your Email address
  • My next of kin is the person we can contact in the event of an emergency?
  • I have been referred to this practice by*

  • Health Cover Information

  • Account Holder*

  • Consent

  • SOMNOCARE PRIVACY POLICY

    Somnocare takes all reasonable measures to operate in accordance with the Privacy Act 1988, the Freedom of Information Act 1992 (WA) and the Australia Department of Health guidelines.

    These acts and guidelines provide a framework that governs how medical and health services collect and use your personal and health records.

     

    Collection of your information:

    We must collect necessary personal and medical information to properly treat you. This information may include, but not be limited to:

    Personal and family medical histories
    Ethnicity background
    Contact details
    Medicare and health fund details
    Account and billing information

     

    This information will typically be collected directly from you, however Somnocare may also collect related medical records from other health providers who have been, or are currently involved in your holistic healthcare. These may include general practitioners, medical specialists, hospitals or allied health professionals. In the unlikely event you are unable to provide necessary health information (i.e. in emergency situations) we may request information from your nominated next of kin, or other immediate family members (unless, at a prior occasion, you have notified us otherwise).

     

    To read Somnocare's full privacy policies and terms and conditions please click here.

     

    Payments:

    Unless a prior arrangment has been made, any payments are to be made in full either before, or on the day of your appointment. Administrative and processing fees may apply to any outstanding accounts over 14 days, while unpaid accounts exceeding 30 days may require debt collection.

  • Covid-19:

    Upon booking a consultation or testing procedure, you will be asked a screening questionnaire addressing recent travel and any active symptoms for Covid-19. Depending on the outcome of this questionnaire, you may not be able to visit our site until circumstances allow. While under Somnocare's care, you are required to notify us immediately if your situation changes, or if you start to experience any cold and flu like symptoms.

  • I consent to Somnocare using and disclosing my information as outlined in Somnocare's privacy polices, and as outlined in the privacy act and understand that I am required to notify Somnocare if I start to experience any symptoms that could be suggestive of Covid-19.*

  • Note: Without your consent it is unlikely we will be able to proceed with any testing or consultative services. Please contact our rooms to discuss options after submitting this form.

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