Complete Registration Online

Title (optional)

First name *

Surname *

Preferred name (optional)

Date of birth *

Birth sex (optional)

Gender (optional)

Aboriginal / Torres Strait Islander origin (optional)

NoAboriginalTorres Strait IslanderBoth

Ethnicity / cultural background (optional)

Country of birth (optional)

Street address (optional)

Address line 2 (optional)

Suburb (optional)

State (optional)

Postcode (optional)

Mobile *

Home phone (optional)

Work phone (optional)

Email (optional)

Consent to receive SMS (optional)

YesNo

How did you hear about us? (optional)

Next of kin first name (optional)

Next of kin surname (optional)

Next of kin relationship (optional)

Next of kin contact number (optional)

Emergency contact (optional)

Emergency contact is the same as next of kin

Emergency contact first name (optional)

Emergency contact surname (optional)

Relationship (optional)

Emergency contact phone (optional)

Medicare number (optional)

Reference number (optional)

Medicare expiry (optional)

Pension card number (optional)

Pension card expiry (optional)

Healthcare card number (optional)

Healthcare card expiry (optional)

DVA number (optional)

Preferred contact method (optional)

Height (cm) (optional)

Weight (kg) (optional)

Medical history (optional)

Current medications (optional)

Allergies or medication reactions (optional)

Tobacco use (optional)

Tobacco quantity (optional)

Stopped smoking date (optional)

Alcohol use (optional)

Alcohol intake details (optional)

Drug use (optional)

Family history (optional)

Appointment reminders

I consent to receiving appointment reminders.

My Health Record (optional)

I consent to upload my medical record to My Health Record.I do not consent to upload my medical record to My Health Record.

Privacy and consent

When you register, book, attend, contact us or use an approved online service, we collect personal and health information so we can provide safe healthcare, arrange investigations and referrals, follow up results, process claims and payments, communicate with you, and meet legal and professional responsibilities.

I consent to the collection and use of my health information for care and administration.I consent to relevant information being shared with healthcare providers involved in my care.I have read and understood the practicefull Privacy Policy.

Security check

About you

How we can reach you

Next of kin and emergency contact

Medicare and health details

Medical, family, and social history

Preferences and approvals