New Patient Registration Please note: items marked * indicate mandatory fields. 1 2 3 4 5 Personal Details Title MrMrsMissMsDr Membership Contact Details Suburb ACTNSWNTQLDSAVICTASWA Preferred Contact Method EmailHome PhoneWork PhoneMobile Phone Contact Details Emergency Contacts Membership (1 digit next to cardholder's name) Are you a member of the Department of Veterans Affairs (DVA)? * Yes No Membership Medical Information Emergency Contact Emergency Contact Next Medical Information Consent to release medical information* Yes, I consent to the above I give my consent to Dr John Gault, or his agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Dr John Gault, or his agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010. For more information view our Patient Information Privacy Statement. Submit
