PATIENT REGISTRATION FORM

Please take the time to fill out the information below ahead of your scheduled appointment. If you have not yet made an appointment please phone (02) 9997 7346 to do so.

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Please Note: Gap fees apply for Private patients, wait times apply for Public Patients.

Please upload a copy of your referral and any other scans or ultrasounds. 

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PRIVACY CONSENT

By signing below you have read, understood and consent to our Privacy Consent Policy, this includes the collection and use of your personal information for the main care and wellbeing by Dr. Gabby Vasica. 

 

I also give permission for my records to be provided to my referring Doctor and other health care professionals involved in my care by phone, mail, email and fax.  This may also include providing clinical patient records to Medicare, private health funds and hospitals as required for billing and administrative purposes. 

 

This permission does not cover legal reports and reports to insurance companies.