Patient Registration Form

Patient Registration Sheet

Privacy Note

This Practice will collect information about you and your health under the guidelines of the National Privacy Principles 2001. Your attendance, together with your signature on this form will be taken as consent for the collection of this information. It will be used in the course of managing your healthcare and will include referral to additional specialists and allied health carers. Any unauthorised access will not be allowed without your permission. At times it will be necessary to collect health information from family members. Should you have any concerns, questions or complaints about any issue relating to privacy of your personal information, please contact Dr Savvoulidis to discuss the matter.

Patient Information

Concession Details

Cultural Details

Private Health Details

Dr Savvoulidis is a preferred provider with all major health benefit providers except NIB and Mildura Health Fund. If you are with either of these health insurers, you will be charged an increased co-payment should you require surgery.

Doctor and Family Details

Medical Information

It Is important that you answer all of the questions asked

Your Account

Please note that this practice does not bulk bill. All payments for your consultation are to be made in full on the day of your visit. EFTPOS facilities are available. If you are to be booked for surgery you will be charged a Co-payment which is an extra cost. This is not Medicare rebateable and is not covered by your Private Hospital Insurance.

Your Declaration

I accept the said conditions (Please type your name to accept the conditions)

Our Locations

Rose Park Surgery

62 Kensington Road, Rose Park, SA

Westcare Specialist Centre

1st Floor, 28 College Street, Port Adelaide

Contact Us Today

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Contact Details

Phone:  (08) 8331 9177
Fax:       (08) 8331 0355

Surgery Hours

Monday to Friday, 9:00am – 5:00pm

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