Existing patient appointment request

Existing Patient Appointment Request
Name of patient*

First NameLast Name
Birth Date

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

First NameLast Name
Phone number*
Email*
example@example.com
When did you last visit our clinic?*

Less than one year1-2 years2-5 yearsOver 5 years ago
What health concerns do you wish to address?
How can we best help you?

Arrange an appointment to see my doctorArrange an immunotherapy injectionArrange an appointment with a dietitian, Jillian DimockArrange an appointment to see a Nurse Practitioner, Lena JamesProvide information about fees or waiting timesUnderstand what procedures and testing we performOther
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 AriyawansaDr Kate BonehillDr Luke DroneyDr Katharine FosterDr Kathryn HeyworthDr David Heyworth-SmithDr Carl KennedyDr Ji Hye LimDr Ursula McCrannDr Susan PerelDr Babu PhilipDr Kim RobertsonDr Zi TanDr Venetia WhiteheadDr Sophie WillcocksJillian Dimock (Dietitian)Lena James (Nurse Practitioner)
Do you have a current referral from your GP or other specialist?*

YesNo
Referrals from your GP are valid for 12 months from the initial consult.

Referrals from other doctors are valid for 3 months from the initial consult.
Has your referral been sent to our clinic?

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

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Please note referrals are not required for Dr Kate Bonehill, Dr Kathryn Heyworth, Dr Ji Hye Lim, Dr Ursula McCrann, Dr Venetia Whitehead, Jillian Dimock or Lena James.

However, referrals are helpful to assist your care and communication with your healthcare team.
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 is available at short notice?

YesNo
Any other comments or requests
Should be Empty:

Existing Patient Appointment Request