Patient Registration

Your privacy is important to us and the information that you provide below will be kept confidential and only used in accordance with the regulations set out in the Commonwealth Privacy Act 2010. Your contact details will only be used as required in the provision of the healthcare service that you have been referred for. Your contact details will not be used for marketing purposes and cannot be provided to any third parties without your prior consent.

Title *

First Name *

Last Name *

Date of Birth *

Phone *

Email address

Street address *

Suburb *

Postcode *

State *

Do you have a Medicare?

(No)

Medicare Card Number *

Individual Reference Number *

Are you pregnant?

(No)

Due Date *

Is the patient a child?

(No)

Parent/Guardian name *

Referring Doctor

Name *

Street address *

Suburb *

Postcode *

State *

Is your general practitioner different to the referring doctor?

(No)

Miscellaneous

Do you have a referral form?

(No)

One of the ways we maintain high standards is through teaching, education and research and you may have a trainee doctor, midwife or sonographer involved in your care. If you would prefer not to have a trainee involved in your care or if you have any other questions please indicate this in the comments section below.

By completing this form you give permission to Women's Imaging Group to access any records that may be relevant to the healthcare service that you have been referred for (such as prior scan reports or hospital discharge summaries). I also give consent to send relevant information to relevant medical third parties.

I understand and accept the risk associated with transmitting the report of my ultrasound and images via unsecured email to my email address if I request. The report will automatically be sent to your referring doctor by a secure network. Please inform reception staff if you require a copy of your report and images.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Download

Mon - Fri: 8:00 am - 5:00 pm

Sat -Sun: Closed

T: 4325 7541
F: 4380 0659
E: [email protected]

Suite 11, 12 Jarrett Street,
North Gosford NSW 2250

Public parking is available in the ground floor of our building - enter from Jarrett Street.

Patient Registration