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 KohnDr Jane HoDr Samantha HattleProfessor Simon ClarkeAnissa MoutiAnita GardnerBen ScheulerJasmin JambrakRebecca MonkWalter KirisDr Chris Rikard-BellProfessor Gary WalterDr Ian ShermanDr Peter VauxPatient Title *MrMrsMasterMissOtherPatient's Gender *MaleFemaleOtherPersonal PronounsFirst Name *Preferred NameSurname *Date of Birth (please utilise the calendar only, this pops up when you click in the box below) *NextPatient's Email *Patient/Guardian's Primary Phone Number *Additional Phone Number(s)Guardian/Contact NameNext of Kin Name *Next Of Kin Relationship *Next Of Kin Contact Number *Patient's Residential Address (no postal addresses will be accepted) *Patient's Residential Suburb *Patient's Residential Postcode *PreviousNextValid Referral and/or Additional Documentation (jpeg, jpg or png files only) * Click or drag a file to this area to upload. Medicare Card (jpeg, jpg or png files only) * Click or drag a file to this area to upload. Account Holder Name *Account Holder Date of Birth (please utilise the calendar only, this pops up when you click in the box below) *PreviousNextPatient Policy and Consent *By checking this box, I confirm that I have read and agree to the Total Health Care Terms of Service and Consent. I understand that these terms may be amended from time to time and agree to be bound by the current version published on the Total Health Care website. I acknowledge that continued use of services constitutes acceptance of any updated terms. It is my responsibility to review the terms periodically for any changes. A copy of the current Terms of Service and Consent can be accessed by opening the following link in a new browser tab in a new browser tab https://www.totalhealthcare.net.au/terms-of-service/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
