Patient Registration

Do you use another first name? Leave blank if you don't use another name *

Date of Birth (DD/MM/YEAR) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Preferred Contact No. *

Can we contact you via SMS? *

Yes No

Email - if you give us an email address, you agree to receive correspondence via email *

Emergency Contact - Firstname + Surname *

Relationship to you *

Contact number (pref. different to yours) *

WHO IS YOUR GP (local doctor) or CLINIC, if different from who has referred you? *

Do you need an interpreter at your consultations? *

Yes No

If so, what language? *

Are you of Aboriginal or Torres Strait Islander origin? *

Aboriginal Torres Strait Islander Neither Aboriginal or Torres Strait Islander

Do you have any other specialists involved in your medical care who should receive copies of correspondence? If so, please list them here. Name and medical specialty. *

South East Colorectal collects the above information on you for the primary purpose of providing quality health care, including an accurate patient record. This information is used for administrative purposes, disclosure to others involved in your health care, for referral on to other doctors and specialists, for hospital admissions, or for medical tests. Our practice has a privacy policy on the handling of patient information and South East Colorectal upholds the highest standards of patient confidentiality. Our practice is also a teaching facility, therefore students may sometimes be in attendance during your consultation. Please advise reception if you do not wish to have a student present during your consultation.
I understand that there will be costs involved in my consultation and that payment of my account is due on the day of my consultation. I confirm that I have read and understood the above and by clicking SUBMIT I give my consent to South East Colorectal to use my information as outlined above.

Patient registration form you can complete this prior to your appointment.

IT'S ABOUT QUALITY OF LIFE!