Patient Detail Form As a new patient please fill out all the required information to request an appointment. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient Information - Step 1 of 4Please select Practitioner *Professor Michael KohnProfessor Simon ClarkeDr Jane HoDr Madhuri JainDr Samantha HattleJasmin JambrakAnissa MoutiEmma LambertJacquelyn FureyAnita GardnerWalter KirisDr Chris Rikard-BellProfessor Gary WalterDr Peter VauxVicki HewsonElizabeth FrigDr Ian ShermanDr Karen ProudmanBen ScheulerPatient Title *MrMrsMasterMissOtherPatient's Gender *MaleFemaleOtherPersonal PronounsFirst Name *Preferred NameSurname *Date of Birth *NextPatient's Email *Patient/Guardian's Primary Phone Number *Additional Phone Number(s)Guardian/Contact NameNext of Kin Name *Next Of Kin Relation *Next Of Kin Contact Number *Patient's Residential Address *Patient's Residential Suburb *Patient's Residential Postcode *PreviousNextValid Referral and/or Additional Documentation * Click or drag a file to this area to upload. Medicare Card * Click or drag a file to this area to upload. Account Holder Name *Account Holder Date of Birth *PreviousNextPatient Policy and Consent *By checking this box I agree to the Total Health Care Patient Policy and Consent. This policy can be reviewed by copying this link into an additional browser tab https://www.totalhealthcare.net.au/policy/Declaration *By submitting this form I declare that all the information is true and correct; I am authorised to make this declaration; I will be the account holder and will be responsible for making all payments as Total Health Care is no longer able to offer split or alternating payments.Reception Team Contact *I understand that a member of the reception team will be in touch with me shortly to confirm the information provided in this form and book an initial appointment that will require payment information to secure this appointmentPreviousSubmit
