New Patient Inquiry

New Patient Inquiry

Appointment information or booking request
Name of patient*

First NameLast Name
Birth Date

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState

Postal Code
Name of parent or guardian if you are arranging on another's behalf

First NameLast Name
Medicare Number and Reference
Phone number*
Email*
example@example.com
What health concerns do you wish to address?
How can we best help you?

Arrange an appointment with a DoctorArrange an appointment with a Dietitian (Jillian Dimock)Book an appointment with a Nurse Practitioner (Lena James)Provide information about fees or waiting timesDiscuss the best doctor to see for my conditionUnderstand what procedures and testing we performOther
Do you have a referral from your GP or other specialist?*

YesNo
Has your referral been sent to our clinic?

YesNo
Please upload your SIGNED referral if we have not already received this

Browse Files
Referral only required for Immunologist Cancelof
Do you have a preference for a doctor you wish to see?

YesNo, just next available
Clinician(s) that you would prefer to see

Dr Krishanthi Ariyawansa (Paediatric)Dr Kate BonehillDr Luke DroneyDr Katharine FosterDr Kathryn HeyworthDr David Heyworth-SmithDr Carl KennedyDr Ji Hye LimDr Ursula McCrannDr Susan PerelDr Babu PhilipDr Kim Robertson (Paediatric)Dr Zi TanDr Venetia WhiteheadDr Sophie Willcocks (Paediatric)Lena James (Nurse Practitioner)Jillian Dimock (Dietitian)
Clinic locations you would prefer to attend (** Your doctor may not attend your preferred site **)

GreenslopesGrangeMount GravattToowoombaTelehealth
Day of the week you would prefer an appointment (** Doctors vary in their schedule availability **)

MondayTuesdayWednesdayThursdayFriday
Best days and times for us to contact you
Would you like to be contacted if an appointment becomes available at short notice?

YesNo
Any other comments or requests
Should be Empty: