New Patient Registration :: Margaret River and Cowaramup Surgery

Contact Information
Name*
Title First Surname
Date of Birth*
MM slash DD slash YYYY
Email*
Phone*
Mobile*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Postal Address
- Same as above
Postal Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bank Account Details
Your bank account details are required for Medicare refund purposes
Account Name BSB Account No

Cultural Identity
To assist with health initiatives - are you Aboriginal and/or Torres Strait Islander?*
Your Nationality/Cultural Background*
Do you require an interpreter service?*
Language spoken

Patient Consent
When you register as a patient of our practice, you provide consent for our GP’s and practice staff to access and use your personal information so they can provide you with the best possible healthcare. Only staffs that need to see your personal information will have access to it under privacy and confidentiality restraint. If we need to use your information for anything else we will seek additional consent from you to do this. Why do we collect, use, hold and share your personal information? Our practice will need to collect your personal information to provide healthcare services to you. Our main purpose for collecting, using, holding and sharing your personal information is to manage your health. We also use it for directly related business activities such as medical claims and payments, practice audits and accreditation purposes, and other business processes for example, Doctor, nurse and staff training.
- I give permission for my personal information to be collected used and disclosed as described above including contact by SMS & Email.
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Phone
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New Patient Registration