Telehealth Patient Registration Form

URL

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Patient Name*

Prefix First Last

Gender*

Male
Female

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Date of Birth*

Address*

Street Address Suburb & Postcode

Mobile number*

Email*

Medicare No.*

Ref No.*

Expiry*

Do you have a pension or concession card? Please ensure you advise our reception staff.*

Yes
No

Is patient a minor?*

Yes
No

Do you consent to receive SMS from our clinic to confirm appointments?*

Yes
No

When would you like to speak to the GP?*

As soon as possible
No rush - sometime today

How did you hear about us?*

Patient Consent - By completing and submitting this form I agree to the following privacy policy.

We require your consent to enable us to handle personal information about you. We use a variety of reminder systems to maintain your health where reminders or recalls may be sent by post, email, telephone or SMS. This practice operates in accordance with the Privacy Act. Please read our privacy policy, and sign below. If you have any queries about this, feel free to ask us for further explanation. I have read the Privacy Policy of Atticus Health and I consent to the disclosure of my personal health information by Atticus Health to other health providers involved in my medical treatment and health care. As part of the preventative health and follow up service offered by Atticus Health, I consent to receive follow up reminders and recalls to be sent to the above address.

Date*

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