If you are seeing Dr Lalith Gamage (Paediatrician) or one of our Psychologists , please fill out the below form and it will be sent to Reception

Personal Details

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Address Details

Language / Nationality Details

Concessions & Private Health Details

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If you are under 17 years of age please fill out the below medicare details for billing purposes
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Next Of Kin Details

Medical Details

Consent Details

Please also be aware that while we offer a recall service for some pathology and reports received, it is still the responsibility of the patient to contact us regarding obtaining results.
Please note, our practice utilises TYRO for claiming and payments of services. Unless arranged prior to your appointment, this requires the full consult fee (including any non-reimbursable gap payment), to be paid on the day. All Pension, Concession Health Care Card holders, DVA Card holders and children under 17 years will be Bulk Billed
It is the policy of the practice to only provide results to yourself or any relevant practitioners involved in your treatment for specific reasons (e.g. referred Specialists, Allied Health, compensation providers etc.). If you wish to authorise any other representative on your behalf Please list them below
On occasion details regarding your health may be shared with relevant third parties pertinent to your healthcare needs; all necessary measures will be met to ensure your privacy and confidentiality. The National Privacy Principles in the Privacy Act sets out how this Practice should collect, use, keep secure and disclose personal information. A copy of our Privacy Policy is available for all patients which outlines the terms in which your health information is managed and utilised.