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Ref Number

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Welcome to my new patient!

Thank you for giving me the opportunity to join you. Communication is a vital part of providing excellent care and you filling in this form will allow me to communicate with you and with your permission, the rest of your team. I look forward to doing everything I can to help you.

See you soon!

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PLEASE ENTER YOUR FULL NAME* This field is required.

First Name

Last Name

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PLEASE CONFIRM YOUR EMAIL ADDRESS* This field is required.

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PLEASE ENTER YOUR DATE OF BIRTH* This field is required.

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PLEASE ADVISE US OF YOUR BIOLOGICAL SEX

Female

Male

Intersex

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PLEASE ADVISE US OF YOUR GENDER IDENTITY

Women

Men

Other, please specify

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PLEASE PROVIDE YOUR GENDER IDENTITY

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WOULD YOU LIKE TO ADD YOUR PARTNER OR A SIGNIFICANT OTHER IN THE COMMUNICATION WITH OUR PRACTICE?* This field is required.

YESNO

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PLEASE PROVIDE THE NAME OF YOUR PARTNER OR SIGNIFICANT OTHER* This field is required.

First Name

Last Name

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PLEASE PROVIDE THEIR EMAIL* This field is required.

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YOUR PRIVACY

{pt2name} will need to sign a consent form online to be included in our correspondence.

Once you have signed, {pt2name} will receive an email inviting them to complete this form too.

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WHAT IS YOUR PREFERRED CONTACT NUMBER?* This field is required.

Please enter a valid phone number.

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PLEASE SUPPLY A POSTAL ADDRESS* This field is required.

Street Address

Street Address Line 2

City

State

Postal Code

Country

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ARE YOU COVERED BY MEDICARE?* This field is required.

YESNO

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PLEASE PROVIDE YOUR MEDICARE DETAILS* This field is required.

Medicare card number

Reference number

Expiry month

Expiry year

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WE WILL NEED A REFERRAL FROM YOUR GP TO CLAIM A MEDICARE REBATE FOR YOU* This field is required.

I CAN UPLOAD THIS NOWI WILL EMAIL THIS LATER

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PLEASE EMAIL YOUR REFERRAL TO adminsupport@drjustintucker.com BEFORE YOUR FIRST APPOINTMENT* This field is required.

OK, GOT ITI PREFER TO UPLOAD IT NOW

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USING THE BUTTON BELOW, PLEASE UPLOAD OR TAKE A PHOTO OF YOUR REFERRAL* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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DO YOU HAVE THE RESULTS OF ANY RECENT TESTS?* This field is required.Eg AMH test, recent ultrasound report, recent sperm test report

YESNO

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WE WOULD LIKE A COPY OF THESE TESTS BEFORE YOUR APPOINTMENT* This field is required.Eg AMH test, recent ultrasound report, recent sperm test report

I CAN UPLOAD THIS NOWI WILL EMAIL THIS LATER

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PLEASE EMAIL YOUR TEST RESULTS TO adminsupport@drjustintucker.com BEFORE YOUR FIRST APPOINTMENT* This field is required.

OK, GOT ITI PREFER TO UPLOAD IT NOW

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USING THE BUTTON BELOW, PLEASE UPLOAD OR TAKE A PHOTO OF ANY RELEVANT RESULTS YOU MAY HAVE* This field is required.Eg AMH test, recent ultrasound report, recent sperm test report

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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DO YOU HAVE PRIVATE HEALTH INSURANCE?* This field is required.

YESNO

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PLEASE PROVIDE DETAILS OF YOUR HEALTH FUND* This field is required.

Health Fund

Membership number

Reference number

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OTHER THAN YOUR GP, IS THERE ANY MEDICAL PRACTITIONER OR PROFESSIONAL SUCH AS A NATUROPATH OR ACUPUNCTURIST YOU WOULD LIKE ME TO KEEP UPDATED ON YOUR PROGRESS?* This field is required.

YESNO

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PLEASE COMPLETE THEIR DETAILS BELOW* This field is required.

First name

Last name

Email

Address

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CONSENT FORM

My medical practice collects information from you for the primary purpose of providing quality care. Providing me with your personal details and medical history allows me to properly assess, diagnose, treat and be proactive in your health care needs. My team will use the information you provide in the following ways:

Administrative purposes in running of my medical practice.
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements
If permitted by you, update any other health professionals involved in your health care on your progress and our plan.

I will make sure that your personal details will remain confidential in accordance with the NSW Privacy and Personal

Information Protection Act 1998. By signing below, you agree that:

You are happy for me to discuss your medical history, diagnosis, and our management plan with your referring doctor and any other relevant medical specialists as required
You understand you are welcome to access your medical records at my practice
You are responsible for and understand the fees associated with your care
The information you have supplied is accurate

If your information is to be used for any purpose other than the above, your consent will be sought.

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How did you hear about our practice?* This field is required.

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Signature* This field is required.

Clear