BHCKids Geelong Patient Registration e-Form

Geelong Patient Registration e-Form

Please fill out the following Patient Registration Form with your details and click the submit button at the end. We will contact you after we receive your completed form.

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

Child's (Patient) Details

Date of Birth

Address


Parent 1 Details and Medicare Card Account Holder

Date of Birth

Parent 2 Details


Medicare Card Details


PRIVACY INFORMATION AND CONSENT

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

Patient/Guardian will report to the clinic staff immediately if they have any COVID-19 symptoms or have been exposed to any tier sites or they believe may be at risk of COVID-19 for any reason.

I consent to all the above: Yes, No

Payment Details

Credit Card Type
Card Number:

Please upload referral or related documents