New patient registration

Patient Details

First Name *

Middle Name(s) (If Any)

Surname *

Preferred Name (If Any)

Patient Gender *

Date of Birth *

Street Address *

Suburb *

State *

Postcode *

Postal Address (if different)

Cultural Background

This information is optional, but assists us to provide relevant healthcare that meets your needs.

Indigenous Status

Knowing this information will help us provide relevant healthcare that meets your needs.

Ethnicity

Patient Medicare Card Details

Medicare Card Number *

Reference Number (IRN) *

Expiry *

First Parent / Guardian Details (Primary Contact)

Title *

First Name *

Last Name *

Relationship to Patient *

Contact Number *

Email Address *

Second Parent / Guardian Details (Secondary Contact)

Title

First Name

Last Name

Relationship to Patient

Contact Number

Email Address

Consent

I confirm that the above information provided is true, complete, and accurate. I am aware that I am responsible for payment of the agreed consultation fees at the end of the consultation. I agree to a cancellation fee of $100.00 if an appointment is cancelled within 24 hours of the agreed time, and a fee of $70.00 for any out of appointment requests (unless agreed in advance). I am aware that all information provided will remain confidential.

I consent to being contacted by the practice: *

This consent (if given) allows us to contact you directly using the above preferred method.

I consent to the collection of patient information: *

This consent (if provided) allows us to attempt to obtain relevant reports from other healthcare providers which are relevant to your child's care.

I consent to the use of computer systems: *

This consent is for the use of use certain privacy protected third-party computer systems (such as AI transcription services) to increase the quality of the care we provide.

Name of person consenting to the above statements *