New Patient Registration

Please complete this form to register as a new patient. Our reception team will be in touch to confirm your registration and eligibility before your first appointment.

Please Note: New patients require approval from the practice before booking. Please submit this form and allow 1-2 business days for our team to contact you. Alternatively, call us on (02) 4394 0866.

Personal Details

First Name *

Last Name *

Date of Birth *

Gender

Contact Information

Phone Number *

Email Address

Home Address

Medicare & Health Fund

Medicare Number

Health Fund

Concession / Pension Card Number (if applicable)

Medical History (Brief)

Current Medical Conditions (if any)

Current Medications

Known Allergies

Preferred Doctor (if any)

Additional Notes or Reason for Registering

I consent to Wallarah Bay Medical Centre collecting and using my personal health information in accordance with the Privacy Policy. *