Patient Registration - Epilepsy Network Australia

Title/Salutation(Required)

Surname(Required)

Given Name(Required)

Date of Birth(Required)

Mobile phone number(Required)

Home phone number (optional, mobile preferred)

Email address

Street Address(Required)

Suburb(Required)

State(Required)

Postcode(Required)

Medicare Number(Required)

Medicare Ref Number(Required)

Medicare Exp Date MM/YY(Required)

Do you identify as being Aboriginal or Torres Strait Islander origin?(Required)

Are your bank details registered with Medicare?(Required)

Occupation

Next of Kin Name

Next of Kin's Phone Number

Referring Doctor(Required)

Referring Doctor Address

Name of GP (if different from referring doctor)

Address or Suburb of GP (if different from referring doctor)

Any other healthcare professionals or specialists. If you would like them to receive correspondence regarding your consultations.

Who is responsible for account payment?(Required)

I have read and accept the fee statement and cancellation fee policy as outlined on this page(Required)

I have read and accept the privacy policy(Required)

I am happy for medical correspondence regarding my care to be transmitted via email(Required)

I will notify staff if correspondence regarding my personal and medical information should not be sent via email(Required)

If you have a tele-health consultation, and are eligible for bulk-billing, do you consent to assign your medicare rebate to the doctor?(Required)

Consent

Contact for approved research

Dear Epilepsy Network Australia patient,

The doctors at Epilepsy Network Australia are active in both local and International medical research in the field of epilepsy. New studies commence all the time and occasionally we are involved in recruiting patients for clinical trials.

You are treating specialists are up-to-date with current, local clinical studies and research trials that are recruiting and it may be that they identify you is a suitable candidate for participation.

We would like to contact you if your doctor thinks you would be eligible to participate in such a study. Examples of this include questionnaires, telephone interviews, physical therapies and occasional medical therapies.

This consent form is designed to indicate your willingness to be contacted regarding potential future studies, but does not imply that you consent to be involved with any study. You are able to withdraw consent from this process at any time by calling 03 7066 4607, or speaking with your doctor.

Consent(Required)

Use of AI-powered scribing software in this practice.

Dear Epilepsy Network Australia patient,

To assist with accurate and efficient documentation, this practice uses AI-powered scribing software during consultations. This technology supports secure and streamlined medical record-keeping while maintaining strict privacy and confidentiality standards. If you have any concerns or wish to opt out, please inform the practice in writing.

Click on this link to read and review our Privacy Policy.

Privacy & Financial Consent

Please scroll to the bottom, read carefully, and tick “I Agree” to continue.

1 | Who We Are

Epilepsy Network Australia Pty Ltd (“ENA”, “we”, “our”, “us”) is a specialist neurology service based in Melbourne. Details about our clinical team and ethos can be found on our About Us page.

ENA complies with the Privacy Act 1988 (Cth), the Australian Privacy Principles (APPs), and relevant State health-records laws (e.g. Health Records Act 2001 (Vic)).

2 | What Information We Collect & Why

Category	Examples	Purpose
Personal	Name, DOB, address, phone, Medicare	Identify/contact you
Health	Medical history, results, treatment notes	Provide care
Payment	Cardholder name, tokenised card data	Process fees
Usage	Secure link opens, IP/device	Audit/security

If you choose not to provide certain information, we may be unable to offer you the full range of services or tailor your care appropriately.

3 | How We Collect Information

– Directly from you (form, phone, email, clinic)
– From GPs, hospitals, other providers
– From Medicare, MHR, TAC/WorkCover, carers
– Via secure payment portals

4 | Payment Security & Card Storage

We use StripeLink or an equivalent PCI-DSS certified platform.

1. Card entry is via secure iFrame; ENA can't see your card.
2. Verification may use SMS or bank app (3-D Secure).
3. A secure token is stored; no card data is stored.
4. Deleting the card redacts the token irreversibly.

5 | Use & Disclosure of Information

Recipient	Purpose
Intake providers	e.g. StripeLink – secure card processing
Healthcare providers	Doctors, labs, hospitals
Legal bodies	Medicare, courts, Services Australia
IT vendors	Cloud hosting/support with NDA

We share data only when necessary for care or required by law.
Overseas disclosure: We prefer Australian storage; offshore vendors must comply with APP 8.

6 | Data Security & Retention

– Records encrypted in transit/rest, backed up nightly.
– Physical notes secured.
– Retention: 7 years post-contact or until 25 for minors.

7 | Your Rights

You may request access, correction, transfer, token deletion, or withdraw consent (with exceptions). Admin fees may apply.

8 | Financial Consent

By ticking “I Agree”, you authorise ENA to:

1. Validate/store card via StripeLink (tokenised).
2. Charge your card for services as per fee schedule.
3. Charge no-show or cancellation fees.
4. Seek payment if third-party approval is missing.
*Pre-approval is required for TAC before 14 Feb 2018.*

9 | WorkCover / TAC Accounts

You must supply written insurer approval. Otherwise, you are liable for the account.

10 | Complaints & Contact

Epilepsy Network Australia
Tel: 03 7066 4607
Email: [email protected]

We respond to privacy complaints within 30 days. If unresolved, contact the OAIC (oaic.gov.au | 1300 363 992).

(Last updated July 2025 – Version 1.1)

I Agree to the Privacy & Financial Consent

Note: Scroll to the bottom of the consent text above to enable this checkbox.

💳 Secure Card Validation

No payment now – just a quick card validation to secure your appointment.

Cardholder Name Card Number

Expiry Date

CVC

🔒 Powered by Stripe. Your card is never stored on our servers.

Name

This field is for validation purposes and should be left unchanged.

Doctor’s Fee Statement

Please Note: This practice does not Bulk Bill (with the exception of people who identify as Aboriginal or of Torres Strait Islander origin).

Consultation Item Numbers & Service Fees:

Complex Initial Consultation (45 mins)

Standard Fee $520

Medicare Rebate (approx) $259.40

Initial Consultation

Standard Fee $380

Medicare Rebate (approx) $148.35

Complex Review Consultation (20 mins)

Standard Fee $245

Medicare Rebate (approx) $129.90

Review Consultation

Standard Fee $175

Medicare Rebate (approx) $74.25

Telephone Review Consultation

Standard Fee $110

Medicare Rebate (approx) $42.30

EEG

Standard Fee $370

Medicare Rebate (approx) $119.25

Please note: We do not see patients with workcover or TAC claims

Cancellation policy:

Please note appointments cancelled with less than 48 Hours notice (excluding weekends) will be charged a cancellation fee of $200 for NEW appointments and $100 for REVIEW appointments.

The consultation fees increase every year in line with the Australian Medical Association industry fee guidance, November of every year. Patients with financial difficulties should bring their circumstances to the attention of the staff or the doctor. Accounts referred to a collection agent or solicitor will have all legal costs and commission added to the amount due.