Please complete the form below and click the SEND FORM button. If you need any assistance, please give us a call on (07) 3207 8222.
Please provide at least one phone number
(Someone we can contact if needed urgently)
Reminder System - Our practice provides our patients with preventative care and early case detection reminders. e.g. immunisations, annual health checks, skin checks and pap smear.
Enter the date below if you have had immunisation. Leave blank if not. (MM/YYYY)
If completing this form for a child, are their immunisations up to date?
When did you last have the following...
Please provide details of any current medication and treatments (including over the counter medications, vitamins, minerals, etc.)
We require your consent and personal information about you to use for reminder letters which may be sent to you regarding your health care and management.
Victoria Point Surgery, 1 Bunker Road, Victoria Point 4165Phone: (07) 3207 8222 - Fax: (07) 3207 9333
As a patient of our medical practice we require you to provide us with your personal details and a full medical history, so that we may properly assess, diagnose, treat and be proactive I your health care needs.
We require your consent to collect personal information about you and to use the information you provide in the following ways. Please read this consent form carefully, and sign where indicated below.
You can decline to have your health information used in all or some of the ways outlined above but it may influence our ability to manage your health care to provide the best outcome to you.