Patient Details

Patient Information

Title

First Name *

Last Name *

Street Address *

Suburb *

State/Territory *

Postcode *

Date of Birth *

Gender *

Cultural Background

Email Address *

Occupation

Phone (* at least one required)

Home

Mobile

Work

Patient Medicare Information

Medicare Number *

Reference Number (IRN) *

Expiry *

Dept. Veteran Affairs Card Number

Expiry

Emergency Contacts

Next of Kin Name *

Relationship *

Contact Number *

Emergency Contact Name *

Relationship *

Contact Number *

Privacy Consent and Information

How did you hear about Terrigal/Avoca Beach Medical Centre?

Terrigal and Avoca Beach Medical Centre’s take our patient’s privacy seriously.

We require your consent to collect, use and disclose information about you for the primary purpose of providing quality healthcare. We store your information digitally on a secure firewall-protected server.

Please read the following information carefully. We encourage you to ask questions or seek clarification if needed.

By selecting below and submitting this form (as a patient or guardian of a patient), you acknowledge the following:

PLEASE REMEMBER TO ADVISE YOUR DOCTOR OF ANY ALLERGIES

Patient Details

Terrigal

Avoca Beach

COVID-19 Vaccinations

COVID-19 vaccination information

COVID-19 vaccination bookings

GP Appointment

Location bookings

COVID-19 Digital Certificate

Patient Alert