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GastroNorth Patient Registration Form
Address *
Address
Suburb
State
Postcode
Gender
Are you happy for us to communicate with you via email:

Health Care Provider Information

Colour of Medicare Card

Blue Pension Card Holder

DVA Card Holder

Overseas Patients

Work Cover / TAC

Referring Doctor Clinic Address
Referring Doctor Clinic Address
Suburb
State
Postcode
How did you hear about us? *

CONDITIONS OF TREATMENT

Payment is required on the consultation day. Should payment not be made on the day I acknowledge I will pay any additional account fees/charges that may be incurred until account is paid in full. I understand it is my responsibility to ensure a current referral.

CANCELLATION POLICY

If for any reason you need to reschedule or cancel any future appointments we will require 48 hour notice
or you may be charged a $50 late cancellation fee.

We often have a long waiting list of patients and this timeframe allows us to offer your appointment to other patients.

PRIVACY PATIENT INFORMATION

To provide a high standard of medical care we need to collect personal information from our patients. This information is usually collected from the patient but may be collected from family members and other healthcare providers with the patient’s consent. At times some of this information needs to be shared with other health care providers or we may be legally bound to disclose personal information. All persons accessing your personal health information are bound by confidentiality. Please do not hesitate to discuss any concerns, questions or complaints about any issues related to the privacy of your personal information with your doctor.

Acknowledgement *