Other

Other Appointments

Are you a new patient at Highgate Health? *

YesNo

Have you had an appointment with Highgate Health in last 4 Months? *

Yes NoNot Sure

Title *

Gender *

First Name *

Middle Name

Last Name *Please use legal name as per Medicare (No hyphens please)

Preferred Name

Date of Birth *

Mobile Number *no spaces please e.g. 0432123123

Email Address *

Home address *Street address line 2

Suburb *

State *

Postcode *

Do you have Medicare Card? *

YesNo

Medicare card number *

What number are you on the card? *

Please provide as much information as possible on what you would like? *

Please feel free to upload any other documents e.g. Pathlogy results or referral

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Please add any documents now so they can be uploaded into your patient records

I have read and agree to the :

Medical Practice Privacy and Telehealth Consent Form

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