Patient Information Form

Patient Information

To assist us with your consultation please complete the following online form prior to your appointment.

Alternatively you can download a PDF of the form to complete manually here. Patient information

Title

First Name *

Surname *

Address

Street / PO Box *

Suburb / City *

State *

Post Code *

Date of Birth *

Email *

Phone H /W

Mobile *

I DO NOT want to receive SMS reminders for my appointment

Next of Kin *

Relationship

Phone Contact *

Usual Doctor

Usual Doctor’s Practice

Health Insurance

Medicare Card Number *

Reference No. *

Expiry Date *

Private Health Insurance *

Name of Health Fund *

Policy No.

Type of Cover

Do you have a DVA Card?

Is this a Work Cover Claim? (if yes, please notify reception)

How did you hear about us? *

Other, Please specify

Your Privacy, Our Concern – Consent to use your personal information

Dr Ian Baxter and The Sunshine Coast Medical Weight Loss Centre complies with the Commonwealth Privacy Act and all other state and territory legislative requirements in relation to the management of personal information. We collect information that is necessary for the provision of your health care. Personal information obtained from you in your consultation may be used to provide information to various health services involved in supporting your health care management (e.g. pathology, radiology, hospitals or other specialists).

I have read and understood the Privacy Policy and understand my rights and responsibilities.

I hereby consent to my personal information being released as and when required *

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(07) 5444 8594

Patient Information

Buderim

Morayfield

Regional Queensland

Opening Hours