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Geelong Patient Registration e-Form

Please fill out the following Patient Registration e-Form with your details and click the submit button to confirm your appointment as required.

(Please fill out all the fields) (Form: geelongpaedinitial)

Child's (Patient) Details

Date of Birth

Parent 1 Details (Primary account holder and person to contact)

Date of Birth

Medicare Card Details

PRIVACY INFORMATION AND CONSENT

** Please click here to read the Privacy & Parent Consent Information before continuing with this form (pdf file)

Yes, I agree to the privacy and parent consent information above.
Are there any court orders relating to the powers, duties, responsibilities or authorities of any person in relation to the child or access to the child? If so, please upload the most recent document below. Our Patients with Separated Parents Policy can be found here.

Yes
No
Our clinicians are implementing a medical AI scribe service to dedicate their full focus on you during your visit while maintaining an accurate and thorough record of your care.

If you do not wish to use this service, please inform your clinician at the beginning of your consult.

Payment Details

Credit Card Type
Card Number:
Please upload referral or related documents