Patient Registration

Use this form only if this the first time you are visting us.

Click here to walk in if you have visited us before.


Fields marked with * are compulsory













Next of Kin





Employer Details

Put NA in employer details if not applicable






RE:  GP visit to the practice will be charge at the casual rate, all other services that is provided outside of a standard GP consult (etc. ECG, Labtest services and ACC) will apply extra charges. 

Payment is expected at the time of consultation. If unable to pay today, I agree to pay within 7 days and if remaining unpaid, I agree to pay collection costs for the recovery of my account.  I am aware that outstanding debts are placed with a national collection agency and that a MINIMUM OF $45 PLUS AGENT’S FEES will be added to any outstanding amount.