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