Details Form

Personal Details


Address Details

Language / Nationality Details

Concessions & Private Health Details

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

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.

Referral Upload

Click or drag a file to this area to upload.
Do you have a copy of your referral? Please take a photo of it and upload it so we enter all your information before your appointment. Please also bring your referral on the day
Click or drag a file to this area to upload.
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In keeping with SA HEALTH guidelines, its a requirement when you attend Ladywood Clinic that you check in via the QR code or sign in manually.
We also require everyone to wear a mask including those who may have an exemption.
From Tuesday the 23rd of November 2021 staff will be requesting proof of your COVID-19 vaccination status upon entry of anyone above the age of 12 yrs.
If you are un-vaccinated we will be offering telephone appointments only – if during your consult the doctor needs to see you face to face they will organise a time depending on the urgency.
Ladywood Clinic have introduced this policy to provide a safe work environment for all our staff and for vulnerable patients with compromised immune systems.