Patient Registration "*" indicates required fieldsPhoneThis field is for validation purposes and should be left unchanged.Personal detailsName* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Preferred nameD.O.B*Gender* Male Female Prefer to self describe as (see below field) Prefer not to sayGender descriptionPronounsPhone*Email*Address* Street Address Suburb Post code Medicare number*Reference number*Expiry date*Please select if you have any of the following Private Health insurance Veterans Affairs card Pension card Healthcare cardPrivate health insurance fund nameMembership numberVeteran's Affairs cardType White GoldPension card numberPension card expiry dateHealthcare card numberHealthcare card expiry dateIs the patient under 18 years old?* Yes NoParent / Guardian Name First Last RelationshipD.O.BMedicare numberReference numberExpiry dateI approve electronic communication, e.g. appointment reminder via SMS to my mobile:* Yes NoIs your referral from your usual GP?* Yes NoGP Name DrDr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last GP PhoneClinic nameGP Address Street Address Suburb Post code Are there any other health care practitioners to whom correspondence should be sent?* Yes NoPlease provide the details, including addresses, of other health care practitioners:Next of kinName* First Last Phone*Relationship*Consent & Signature I confirm that I have read the privacy statement & cancellation policy and consent to these terms. I give my consent to the use of my personal information in the listed circumstances. I recognise that I have the right to withhold any information, but this may compromise my medical care. I consent that my personal details may be used to retrieve medical information including reports and results from medical facilities outside this medical practice. I am aware I can request that a specific health professional does not have access to my personal information.I confirm that I have read the privacy statement and cancellation policy and consent to these terms. I also confirm that the information given above is true and accurate to the best of my knowledge –* YesSignature*Date*
