New Patient Registration

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New Patient Registration Form


Please note: items marked * indicate mandatory fields.

Personal Details

Personal Details

Name *

Contact Details

Address Line 2

Membership

Emergency Contact

Partner Name

Next of kin Name

Medical Information

Specialist Name

Consent to release medical information *

I give my consent to Dr Ben Dodd, or their 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 Ben Dodd, or their 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 on this website.