Consent and New Patient Registration Form

Dr Anupam Pokharel, whom you are seeing, is a psychiatrist. You need a valid referral from a medical practitioner to consult him. Dr. Pokharel works at Mitcham Private Hospital on a sessional basis.

This medical practice collects information from you for the primary purpose of providing quality healthcare. We ask you to provide us with your personal details and a full medical history, so that we may properly assess, diagnose, treat and be proactive in your healthcare needs. We may use the information you provide for administrative purpose in running our medical practice, including billing and compliance with Medicare and Health Insurance Commission Requirements. Information may be sent to other practitioners involved in your care. Condentiality will always be maintained if any information related to your care is used for research or quality assurance purposes.

Dr Pokharel will ask you details about the history of your condition in addition to some more general questions, which are relevant to your psychiatric status. The examination cannot be conducted with children, especially small children, in the examination room. A support person may accompany you during the consultation.

If you need to cancel or reschedule an appointment, Appointments should always be canceled or postponed as soon as possible. A minimum notice of 24 hours (or 1 business day) is required, otherwise, a fee will be payable. If notication of cancellations or reschedule occurs with less than 24 hours (or 1 business day), then the schedule of fees will be as follows: 1stoccasion: $ 100; 2nd occasion and onwards: entire consultation fee. Fees charged for missed/canceled appointments are not Medicare rebatable.

In case you need to contact him other than your pre-organized appointment, please note that Dr. Pokharel does not have a capacity to respond in an emergency. Dr. Pokharel will try to respond within 2 business days. Please contact your GP, local hospital emergency department or local public mental health service psychiatric triage in the event of psychiatric emergency or if you need any immediate help.

In case of telehealth, all video consultations including messages, voice, video, and content are encrypted using AES 256-bit encryption. Consultations are not recorded. In case of technology failure, psychiatric consultation may need to be repeated by telehealth or a face to face assessment may need to be organized.

If you are not eligible for Medicare, please check with your overseas student health cover or visitor health cover for any rebate. You will still need a valid referral. You may enquire about items 291,293, 296, 304 and 306.

First Name

Surname

Date of Birth

Gender Male Female

Phone

Email

Address

City

State

Post Code

Next of Kin

Realtionship

Contact Number

Medicare Number

Reference

Medicare Expiry

Private Health Fund

Membership Number

DVA Membership Number

Pensioner/Health Care Card Number:

Work Cover / TAC Details (If applicable)

Claim number:

I consent for psychiatric assessment and treatment under above stated terms and conditions.

I agree

Submit