Casual/Visitor Patient Enrolment Form

Enrol as a casual patient or visitor

This enrolment form is required by all casual patients or visitors who are not enrolled as patients with our clinic. We require completion of this form before your doctor’s appointment.

    * Required Fields



    FemaleMaleGender Diverse









    YesNo




    Current GP
    YesNo


    Agreement and Acknowledgement

    NB. Parent or Caregiver to sign if you are under 16 years

    • I acknowledge that I have reviewed the relevant fees displayed/provided to me for services rendered.
    • I acknowledge to pay for all consultation and service costs at the time of my appointment or request for service.
    • I acknowledge any payment not completed at the time of my appointment or request for service will incur an additional $15.00 administration fee.
    • If unpaid after 30 days from the date of service, my account may be placed in the hands of a debt collection agency and all costs associated with this will be my responsibility to pay.





    Your Signature: