New Patient Appointment Request Form

Salutation:*

First Name:*

Last Name:*

Mobile Number:*

Email address:*

Date of Birth:*

Which state are you currently living in?*

What services would you like to book:*

Do you want to book a Face-to-Face appointment or Telehealth appointment?*

Some of our clinicians only accept Face-to-face patients, some only accept Telehealth patients, some accept both. We appreciate if you could state your preference clearly.

Which patient type are you?*

Please note we are a private clinic and do not offer bulk-billing service. We do not accept any workcover / CTP / medico-legal patients unfortunately, please check with your GP for other options.

Main presenting problem:*

How did you hear about us?*

Please select all that apply

Upload your referral letter*

A referral letter is compulsory at the time of booking request. This is essential for us to assess the suitability. We only accept PDF (preferred) or JPG.

Drop files here or

Accepted file types: pdf, jpg, Max. file size: 10 MB.

Message (Optional)

We kindly request you to read our Fee and Booking Policy before requesting an appointment.

New Patient Appointment Request Form