Appointment Request Please note: items marked * indicate mandatory fields. Personal Detail Title - Select -MrMrsMissMsDr First name Last name Preferred name Gender - Select -MaleFemale Date of Birth Please enter date using the format DD/MM/YYYY Contact Details Address Suburb State - Select -ACTNSWNTQLDSATASVICWA Postcode Email Home Phone Please enter phone number with area code included. No spaces please. eg. 0298765432 Work Phone Please enter phone number with area code included. No spaces please. eg. 0298765432 Mobile Phone Please enter your full mobile number. No spaces please. eg. 0412345678 Preferred Contact Method - Select -EmailHome PhoneWork PhoneMobile Phone Memberships Medicare Number 10 Digits Medicare IRN 1 digit next to cardholder's name Medicare Expiry Date Please enter "Valid To" date - using the format MM/YYYY Private Health Fund Name Private Health Fund Number Are you a member of the Department of Veterans Affairs (DVA)? Yes No Department of Veterans Affairs (DVA) Member Number DVA Card Level - None -GoldWhite Orange Do you require DVA transport booked for you? Yes No Emergency Contact Partner Name Partner Phone Please enter phone number with area code included. No spaces please. eg. 0298765432 Next of kin Name Next of kin Phone Please enter phone number with area code included. No spaces please. eg. 0298765432 Relationship to next of kin Medical information Referring Doctor Name Referring Doctor Phone Please enter phone number with area code included. No spaces please. eg. 0298765432 Reason for requesting a consultation If you have a health condition that concerns you, please describe below. Appointment Details Preferred appointment date Please enter date using the format DD/MM/YYYY Preferred appointment time - Select -MorningMidday Afternoon Preferred Doctor - Select -First AvailableDr Gary McKayDr Maroof KhanDr Santee SanthanamDr Sebastian RodriguesProf Chris Berney Appointment Type - Select -First Appointment Follow Up Appointment Consent to release medical information I give my consent to Colorectal Surgeons Sydney, or their agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Colorectal Surgeons Sydney, or their agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010. For more information view our Patient Information Privacy Statement. Yes, I consent to the above. Leave this field blank Banner Image
