The Snowflake Clinic

Personal Information

Please complete the questions that apply to you.

Questions with an asterix (*) must be answered.

First Name *

Last Name *

Date of Birth *

Gender *

FemaleMaleIdentify as other

Postal Address - Number and Street Name (or PO Box) *

Suburb *

State *

Postcode

Mobile Phone Number *

Other Phone Number

Email Address

Can we leave messages at the above e-mail address and phone numbers? *

Medicare Card Number (no spaces)

Expiry Date on Medicare Card

The number next to the patient's name on the Medicare card

NDIS Registration Number (if applicable)

NDIS Plan Expiry Date (if applicable)

Name of GP / Doctor

Doctor Contact Phone Number and Address (if known)

Emergency Contact Person

Phone Number for Emergency Contact Person

Patient's relationship to the emergency contact person

Do you have a My Health Record?

YesNoDon't Know

If yes, do you give us permission to access your My Health Record?

YesNo

Do you identify as Aboriginal or Torres Strait Islander?

YesNo

Do you have a referral or other document you would like to provide us?

Browse

Click on the "Browse" button to upload a doctor's referral or any other document directly from your computer or phone. (If needed you can even take a photo of the referral with your phone and then upload the image.)

Tick this checkbox to indicate you have read our privacy policy at the web address http://www.snowflakeclinic.com.au/other-information.html, and that any questions you have asked about it have been answered satisfactorily. *

Comments or Requests (if any)

Thank you for completing this form. When finished, please click or tap the Submit button below and your responses will be sent through to The Snowflake Clinic. If you have not already organised an appointment, someone from our office will be in contact with you within the next three business days.

If you have any queries, contact us by e-mail at admin@snowflakeclinic.com.au