Who do you wish to register? First Name Last Name What is the patient date of birth Age What is the patient gender —Please choose an option—MaleFemaleOtherUnknown Address Post Code City/Suburb What is your preferred contact no. Mobile Phone Alternative Number E-mail What do the symptoms relate to? —Please choose an option—Rashes & SkinEar, Nose & ThroatTummy / GastroUrinary InfectionsInjuriesAches & PainsNone of the above Select all your symptoms: How long have you had these symptoms: —Please choose an option—0-3 Hours6-12 hours12-24 Hours1-3 DaysMore than 3 Days Please describe Payment Option —Please choose an option—MedicareDVAPrivate Health FundCredit Card Medicare No. Medicare Ref No. Expiry Date DVA No. Insurers —Please choose an option—AllianzBupaMedibankNIBHCFOthers Insurers No. Do you have regular practice? —Please choose an option—YesNo State —Please choose an option—NSWQLDSATASVICWAACTNT Practice Suburb Practice Name Do you have regular doctor? —Please choose an option—YesNo Doctor Name
