Enquiry & Appointment Request Form vDec 2024

General Enquiry & Appointment Request Form

Dear Patient/Enquirer - if:

a surgeon if referring you to us (even if we have seen you before), or
this is the first time you are seeing us, or
you have seen us before, but have a different health issue this time, or
you have not seen us for a year

Please complete our Patient Registration Form first - it may be found on the Form tab

Title *

MrMrsMsMissDrOther**

**If Other, please give details

First Name *

Last Name *

Date of Birth *

Your Mobile Phone Number (or other phone number with area code, if you have no mobile) *

Email Address *

Please advise what you are contacting us for *

Appointment - renal/kidney/urinary tract issueAppointment - pre-surgical medical assessmentAppointment - hypertension (high blood pressure)Appointment - deep vein thrombosis (DVT)Appointment - post-hospital reviewAppointment - annual Appointment - follow-up/review to a previous rooms appointmentOther (please specify below)

If "Other" above, please specify what you are contacting us for

If you would like to make an appointment, please choose your preferred morning/s (please note that there is a wait for appointments of approximately 4-5 weeks)

Monday morningTuesday morningThursday morningFriday morningAny

Please advise your preferred appointment time (allowing 45 mins for renal/kidney/complex issues, 30 mins for pre-surgical assessment/most other new referrals, 15 mins for follow ups)

10:00 am10:30 am11:00 am11:30 amAny

Are you attaching your referral or other documents? *You need a current written referral to be eligible for a Medicare Rebate (Specialist referrals last for 3 months, GP referrals last for 12 months)

Do you wish to be placed on a cancellation list (if your email is about making an appointment)? *We can place you on a cancellation list, once we have your Patient Registration Form, written referral and results of any tests which *may* have been ordered by your referring doctor

You may upload your referral and/or any other document/s here.

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