Locations across Queensland within Queensland Cardiovascular Group

Phone (07) 3016 1111

New Patient Registration Form

Complete your new patient registration paperwork online to save time at your appointment.

Contact Details

Postal Address

Contacts

Please enter phone number with area code included.
Please enter phone number with area code included.
lease enter your full mobile number.

Memberships

10 Digits
1 digit next to cardholder’s name
(Valid To)

Emergency Contact

Please enter mobile or phone number with area code included.

Information Disclosure

Confirm if we can we leave messages for you on the “contact phone” defined directly below, identifying the practice as the caller.
The number we can call you on regarding results, or to change an appointment.

I authorise the following person to take messages regarding a reminder / change of appointment / clinical details relating to my healthcare. If you do not nominate someone below, we will only be able to speak with you regarding these points.

Medical Information

Please enter mobile or phone number with area code included.

To claim your rebate from Medicare, your referral will need to be current. Referrals from a GP are valid for 12 months and referrals from a specialist are valid for 3 months. It is your responsibility to ensure your referral is current.

(Drugs or other causes)

Specialist details

If there are any other specialists that require clinical information, please fill the information below.
I give my consent to Queensland Cardiovascular Group, or their agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Queensland Cardiovascular Group, or their agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010. For more information view our Patient Information Privacy Statement on this website.