Patient Authority Form

Book online and we will connect via phone or email to establish an appointment. time. We generally reply to online enquiries within two business days. If your appointment is urgent, please book by calling our office and do not use this booking form. Alternatively call us on (02) 9747 4133

Name (as on Medicare Card) *

First

Last

Preferred Name

Date of Birth *

Phone No. Mobile *

Phone No. - Home or Work

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Emergency Contact Name *

Relationship *

Phone No. *

CARD INFORMATION

Medicare Card Number *

Patient No.

Expiry Date *

DVA / Repat Card No:

DVA/Repat Card No. Type

Gold
White

Pension/HealthCare Card No.

Expiry Date

Type eg:/DSP

Private Health Fund

Membership No.

DOCTOR INFORMATION

Referring Doctor / Specialist *

Family Doctor (if different to referring doctor) *

Authorisation - check box to agree *

I authorise Dr M Herman, Dr V Khoury, Dr S Maze, Prof D Brieger, A/Prof H Raju, Dr C Nalliah, Dr C Wong, Dr P Chandrala, Dr Harshini Sivaramakrishnan, Dr Vicky Chang, Dr Clarence Yeong, Dr Archit Chawla, Dr R Grover, Dr A Moonen, Dr P Snelling, Dr S Sen, & Prof J Rutland to obtain details of my medical history and to forward a copy of their medical letters to other approved medical specialists as part of my care.

Other Doctors seen *

DIGITAL SIGNATURE - (use cursor or finger over keypad) *

Patient Authority Form

CARD INFORMATION

DOCTOR INFORMATION

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