Patient Detail Form As a new patient please fill out all the required information to request an appointment. Please select Practitioner Prof Michael Kohn Prof Simon Clarke Dr Jane Ho Dr Madhuri Jain Dr Samantha Hattle Jasmin Jambrak Anissa Mouti Prof Stephen Touyz Emma Lambert Jacquelyn Furey Anita Gardner Walter Kiris Clare Williams Dr Chris Rikard-Bell Prof Garry Walter Dr Philippa Levy Dr Peter Vaux Vicki Hewson Elizabeth Frig Dr Ian Sherman Dr Karen Proudman Patient Title Mr Mrs Master Miss Other Patient's Gender Male Female Other Personal Pronouns First Name Preferred Name Surname Date of Birth Patient/Guardian's Email Patient/Guardian's Primary Phone Number Additional Phone Number(s) Guardian/Contact Name Next Of Kin Next Of Kin Relation Next Of Kin Contact Number Patient's Residential Address Patient's Residential Suburb Patient's Residential Postcode Valid Referral and/or Additional Documentation Medicare Card Account Holder Name Account Holder Date of Birth Patient Policy and Consent By checking this box I agree to the Total Health Care Patient Policy and Consent. This policy can be reviewed by copying this link into an additional browser tab https://www.totalhealthcare.net.au/policy/ Declaration By submitting this form I declare that all the information is true and correct; I am authorised to make this declaration; I will be the account holder and will be responsible for making all payments as Total Health Care is no longer able to offer split or alternating payments. Reception Team Contact I understand that a member of the reception team will be in touch with me shortly to confirm the information provided in this form and book an initial appointment that will require payment information to secure this appointment Send
