PATIENT REGISTRATION

Please enter at least one phone number

By signing below, I certify that all information provided is true and correct. I understand My Specialists Sydney is a Private Practice and all consultations with a doctor will attract a consultation fee. Pensioner or health care cardholders may receive a discount upon the presentation of a card. I accept all responsibility and liability for my medical bills. I understand that any additional costs that have to be made for the recovery of these fees are my responsibility.

I understand that the doctor may repeat and add more investigations to assist with my diagnosis. I understand that results are not provided over the phone and I will need an appointment to go through my results. I understand that the doctor does not prescribe hormone therapy (including testosterone, clomiphene, hCG, growth hormone, and T3) unless clinically indicated and supported by evidence-based medicine. I understand that the practice promotes safe prescribing and I will need an appointment to obtain a prescription.

By providing my email address or mobile number, I am consenting to use this mode of contact for Tele-consult, recalls, changes in appointments, or billing. I am responsible for advising the practice of any changes, in the future, to my contact details.

I enable this practice to collect relevant and appropriate information about my health and myself. From time to time, the practice may need to obtain or share information with other health providers who may have treated me or may treat me in the future, such as emergency departments, other specialists, or my general practitioner. I give my consent to the collection of information and release it to third parties for these purposes.

Draw signature|Type signatureClear