Patient Forms

NEW PATIENTS: Please complete both registration and health questionnaire 

EXISTING PATIENTS: Please complete the health questionnaire only if you have not done so prior to May 1st 2020. 

Consent:

This Practice collects information for the primary purpose of providing quality health care.

By completing this online registration form you freely give your consent to access health information including pathology, radiology, surgical and medical information which will be used for health care purposes directly related to yourself/your child/dependent as the patient.


Information may be disclosed to others involved in your care including doctors/specialists/pathology or radiology departments outside of this Practice.  This may occur through referral to other doctors or for medical tests and in the reports or results referred to us following the referrals.  The privacy policy of the Practice ensures appropriate management of all patient information.  You understand that any information collected on your behalf will only be used for the purposes for which it was collected.

By completing this form you give your consent to be contacted by SMS/Email and participate in Telehealth/Phone consultations where required. Should you not wish to be contacted via these methods please contact the Practice on P: 03 5561 6038 to discuss further. 


FEES: I understand that I am financially responsible for the balance of any fees charged beyond the Medicare Rebate or if applicable health fund cover.

 

Patient Registration

 
Please select any relevant fields below:
 

Health Questionnaire

 
Please select any applicable
 

P: 03 5561 6038

F: 03 5561 4898

Suite 9, St John of God Hospital,136 Botanic Rd WARRNAMBOOL VIC 3280

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