Patient Registration - The MPC

THE MELBOURNE PSYCHIATRY CENTRE

Patient Registration Form

Please print all information clearly and complete all relevant sections.

Part A: Patient Details


MrMrsMsOther






















Please indicate whether you agree to the following


YesNo

YesNo

YesNo

YesNo

Part B: Regular GP Details


YesNo





Part C: Pharmacy Details





Part D: Billing Details (Private Payers OnIy — See Below for WorkCover/TAC Patients)






Part E: WorkCover. VOCAT or TAC Patients

PLEASE PROVIDE A COPY OF YOUR LETTER OF APPROVAL FOR BILLING PURPOSES

WorkCoverTACVOCATOther