Patient Registration Form | Sea Change Weight Loss Clinic

Contact Details
Title*
Full Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Mobile Phone
Email Address*
Personal Details
Date of Birth*
Height*
Weight*
Occupation
Next of Kin*
Next of Kin Phone(s)
Medical Details
Name of GP*
GP Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
GP Phone*
Other Treating Specialist (if any)
Other Treating Specialist Address
Other Treating Specialist Phone
Medicare Number (10 digits)*
Medicare Ref Number*
Health Fund
Health Fund No.
Pension No.
Veteran's Affairs No.
Basis of Referral
What led to your referral to Sea Change?
- GP's advice
- Other specialist's advice
- Word of mouth
- Previously under care of Dr Gately or Dr McLeod
- Google search or our website
- Our Facebook page
Submit
Your medical records are confidential, however to provide you with the best possible health care it may be necessary to disclose your medical records to or collect them from other health care professionals. To do so, we require your consent.*
- I consent to the disclosure of my medical records to, or their collection from, other health professionals involved in my care. I understand I have a right to deny this request and also that I have a right to access my medical information.

Contact Details