Patient Registration Form | Geriatric Care Australia

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New Patient Registration Form

New patients that would like to arrange a geriatrician consult can fill in the below form online or print the form here.

Patient Information

First Name

Last Name

Address

Date of Birth

Contact Email

Medicare Card No.

Private Health Fund

Medicare Expiry Date

Insurer Membership No.

Mobile Phone

Gender *

Male

Female

Other

ATSI

Aboriginal

Torres Strait Islander

Unknown

Not identified

DVA Card No.

Insurer Expiry Date

Next of Kin Contact Details

Name of Next of Kin

Next of Kin Email

Next of Kin Mobile

GP Information (referral required to book new patients)

General Practitioner Name

GP Location

GP contact number

Upload a GP referral or email to admin@geriatriccareaustralia.com.au, or a GP can complete online here

Upload File

Upload supported file (Max 15MB)

Signature

Geriatric Care Australia collects information for the primary purpose of providing quality healthcare. We ask for personal details and a full medical history so that we may properly assess, diagnose and treat illnesses and be pro-active in healthcare delivery. We will also collect, hold, use and disclose the information you provide in accordance with the Privacy Act 1988 and Australian Privacy Principles (March 2014).

I consent to Geriatric Care Australia requesting copies of my medical records from other providers and to receiving emails and SMS appointment reminders with the contact information I've provided.

I agree to the assignment of the Medicare benefit directly to the doctor (for bulk-billing appointments).

I have read the Geriatric Care Australia Privacy Policy and consent to the use of my information as described.View Privacy Policy

Your Signature

Thank you for submitting, the team will be in contact.

Reminder: Every new patient appointment requires a Referral from a GP, which can be emailed to admin@geriatriccareaustralia.com.au or completed by a GP online here

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Geriatric Care Australia Pty Ltd

A Profit-For-Purpose Enterprise

Email: admin@geriatriccareaustralia.com.au
Hours: Monday to Friday: 9:30am to 5:00pm

Saturday & Sunday: Closed

Phone: (02) 9160 0079
Privacy Policy

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