Patient Registration Form

Fill all required fields (★) to submit the form.

Patient details:

Dr
Mr
Mrs
Ms
Miss
Other:

Responsible Party:

DVA (Gold/White)
Aged Pension
Workcover
TAC

Next of Kin:


Insurance Information:


Referrals:

Dr Aminazad would like all the referrals to be sent no later than one week prior to the scheduled appointment. Specialist referrals are valid for 3 months and GP to specialist referrals are valid for 12 months. You are recommended to have a referral from your GP to last for one year.

Information about Fees:

Dr Aminazad does not bulk bill at his Private Rooms. He attends public clinics at Box Hill, Maroondah and Angliss hospitals.

Payment in full is required on the day of the consultation.
DVA, TAC and Workcover claims will be billed to relevant authorities.
For the details of RSDC fees please call our staff 1300773210.
There is out of pocket cost for Cardio Pulmonary Exercise Test and Home-Based Sleep Study for all patients.

Payment and Cancellation Policy:

In the event an appointment is cancelled with less than 48 hours’ notice, full consultation fee will be charged.


I have read and accept that I am responsible for having a valid referral and for any consultation fees.

Captcha