Please fill out this online form before your appointment.

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    Patient Information

    Parent Information

    Parent 1

    Parent 2


    Person responsible for patient account: Please note a Medicare rebate cannot be processed without the complete and correct details.

    Collection of your information:
    Information about you or your child’s medical and family history is needed to provide accurate diagnosis, treatment and to ensure quality health care. We consider patient health information as confidential and will only collect this information with your consent.

    Use and disclosure of your information:
    Comprehensive care often requires full knowledge of patient health information by other health professionals involved in your child’s treatment. For this reason, with your permission, health information may be shared with other health professionals. It is our usual practice to write to your referring doctor after the consultation, and we will also send you a copy of the letter. Limited information about patients is provided to Medicare and private health funds, for billing and rebate purposes only. We may be legally bound to disclose information, e.g. mandatory reporting of some infectious disease.

    Access to your information:
    You have the right to access your health information. You may wish to view the information or ask for a copy of a part or of the whole record. A small fee may be charged for this service. There may be times when we are unable to provide access, for example, if the privacy of others is affected. You will be advised in this case. Your child’s right to privacy of their health information might at times restrict access to this information by parents or guardians. If you find that information held is not accurate or complete, you are entitled to have that information corrected. With your permission, your child’s health information will be made available to another health practitioner.

    Please do not hesitate to discuss any concerns, questions or complaints about any issues relating to the privacy of your personal information with us.

    Payment of accounts: Full payment is required on the day of consultation.
    • A valid referral from a GP or specialist is required to claim your rebate from Medicare.
    • We would appreciate 24 hours notice if you need to change or cancel your appointment. Appointments cancelled with less than 24 hours notice may be subject to a cancellation fee of $50.00

    Consent: By signing below, I am consenting to (please tick):
    Receiving correspondence (which may include clinical information) via email*
    The use of the patient portal*
    An image being taken as an extra identifier*

    Please be advised that our Privacy Policy is subject to change. Please refer to for the current Privacy Policy.
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