Pre-Appointment RegistrationPlease fill in the the information below to pre-register important information prior to your appointment Name * First Name Last Name Email * Phone (###) ### #### Date of Birth MM DD YYYY Medicare number, patient number, expiry date Private Health Insurance Membership number Emergency Contact First Name Last Name Relationship to Patient Phone (###) ### #### Referring Doctor's Details First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Provider number Privacy Policy The private information entered on this form will not be disclosed to a third party. Your personal information is stored on a secure password protected information system. Onward referral to another specialist will require the duplication of this form, your health record and test results. Your records and information may be kept by your doctor at another location. Your information may be used for billing purposes, including bad debt management. If you do not give permission for the above please let our receptionist know. Consent * I give consent for my personal details to be stored. I do not give permission for my personal details to be stored Thank you for submitting the pre-registration form. Please remember to bring a valid referral from your referring doctor or specialist to your appointment.
