Request a Call Back

Patient Registration Form

Date of birth*

Are you Aboriginal and/or Torres Strait Islander?
YesNo

Are you registering a child?
YesNo

Parent details

Date of birth*

Expiry date

Telephone

Consent to receive SMS text messages and Emailed Reminders or Information?
YesNo

Expiry date

Next of kin

Emergency Contact

NOTE - As a matter of policy, no prescriptions for restricted S8 medication (opioids nor benzodiazepines) whatsoever are given to new patients. This policy has been implemented specifically to discourage drug seekers from wasting doctors’ valuable time.

Medical History

Social History

USE OF HEALTH DATA FOR RECALL REMINDER SYSTEM & QUALITY IMPROVEMENT

This practice uses a recall reminder system & engages in ongoing clinical quality improvement. To do this, access to your de-identified medical information is necessary. This information has no name, date of birth, nor any other identifying features if it is used for clinical audits or medical practice quality assessments. Privacy & confidentiality of your medical record is maintained at all times.

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