New patient registration

Dr Zubair Hasan · MBBS MS MIPH FRACS (ORL HNS) · Provider no. 631413VA

Please complete this form before your first appointment. It takes about 5 minutes. Fields marked * are required.

Your details stay on your device until you press Send to the practice at the end, which creates a signed PDF for you to email to us.

1

Your visit

2

Patient details

If you are completing this for a child or someone in your care, enter their details here.

Medicare

Private health insurance

Department of Veterans' Affairs (if applicable)

3

Emergency contact / next of kin

May we give this person your results and appointment information?
4

Fees and Medicare

This is a private billing clinic. Consultation fees are payable on the day and are not covered by private health insurance.

ConsultationFeeMedicare rebateYour cost

Rebates assume a valid referral and are a guide only; Medicare Safety Net may increase your rebate.

In-rooms procedures are bulk billed. Procedures done during your consultation, such as nasendoscopy (camera examination of the nose and throat, MBS 41764) or ear microsuction / ear toilet (MBS 41647), are bulk billed to Medicare. There is no private charge for these procedures in the clinic.

A. Claiming your consultation rebate

B. Assignment of Medicare benefit for bulk-billed procedures

If an in-rooms procedure is needed, Medicare requires your signed agreement to assign your Medicare benefit to Dr Hasan. The Medicare benefit is then accepted as full payment for that procedure and you pay nothing for it. You can agree now, before your appointment, so there is no extra paperwork on the day.

5

AI scribe consent

Dr Hasan uses the AI scribe built into our practice software, Xestro, to help write consultation notes, so he can give you his full attention instead of typing.

  • With your permission, the consultation is audio recorded and the AI converts the conversation into a draft clinical note.
  • Dr Hasan reviews and corrects every note before it becomes part of your record. The AI does not make any decisions about your care.
  • Dr Hasan will always share these notes with you, along with your GP and referring doctor as part of his usual correspondence.
  • Everyone present in the room must agree. Dr Hasan will also confirm with you verbally before recording starts.
  • You can say no, ask for recording to be paused or stopped at any time, or change your mind for future visits. Your care will not be affected.
  • Your information is handled under our privacy policy and Australian privacy law. Ask us if you'd like more detail on how Xestro stores and deletes recordings.
6

Privacy policy and consent

This clinic collects information from you for the primary purpose of providing quality health care. Federal privacy law requires your consent to this. We need your personal details and full medical history (which may include photographic records) so that we can properly assess, diagnose, treat and manage your health care needs. We will use the information you provide in the following ways:

  • Administrative purposes in running our medical practice, which may include confirming your appointment by SMS or email.
  • Billing purposes, including compliance with Medicare requirements.
  • Disclosure to others involved in your health care, including treating doctors and specialists outside this practice, through referrals, medical tests and the results returned to us.
  • Disclosure to other doctors in the practice, and locums and trainees attached to the practice, for patient care and teaching.
  • Emergency situations in which medical officers or hospitals need access to your notes for treatment.

By signing, I confirm that:

  • I have read the above and understand why my information must be collected.
  • I am not obliged to provide information requested, but not doing so may compromise the quality of my health care and treatment.
  • I am aware of my right to access the information collected about me, except where access may legitimately be withheld, in which case an explanation will be given.
  • The clinic will seek my consent before using my information for any purpose other than those above.
  • I consent to the clinic using my personal information in the ways outlined above.
  • For security, the common area of the clinic is under video surveillance.
  • My results will be communicated by the treating doctor via the SMS or email contact I have provided, and clinic staff will phone me to plan any treatment needed.
  • I am responsible for calling for my results if they have not been confirmed within a week of my appointment.
  • Sydney Northwest ENT uses Doctify to collect anonymous, verified patient feedback. My mobile number may be shared with Doctify only to send an SMS feedback request, verify my review or notify me of a reply. No other personal information is shared and my review is anonymous.

Signature

Signature
Sign here with your finger or mouse
Date:
7

Send to the practice

This creates a signed PDF of your registration. On a phone you can attach it straight to an email; on a computer it downloads so you can attach it to an email to .

Parking at 176 Windsor Rd, Winston Hills
  • Enter via Churchill Dr. There is no vehicle or pedestrian access from Windsor Rd.
  • Visitors can double park at the end of the driveway.
  • The disabled parking space is on the left of the driveway, closest to the entry.
  • The yellow hatched area closest to Churchill Dr can be used as a turning bay.
  • Please give way to vehicles entering the facility to avoid traffic building up on Churchill Dr, and watch for pedestrians.
  • If the car park is full, please park on the street and walk in along the left side of the driveway.
Sydney Northwest ENT · 176 Windsor Rd, Winston Hills NSW · Appointments (02) 7813 6672