PATIENT REGISTRATION

Online form

For your convenience, you can complete your Patient Registration Form online below.

The form is sent via standard email security protocols. Alternatively, you may download a PDF Registration Form to email to our practice.

Please enter at least one phone number below

If patient is a child: the following details are required for Medicare benefits to be paid to the adult account

Full address please

Please include area code

Full address please

Please include area code

  Workers Compensation & Third Party Only  

Click to reveal additional fields

Please include area code

Please include area code

Full address please

CONSENT TO COLLECT PATIENT INFORMATION

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in the following ways:
- Administrative purposes in running our medical practice.
- Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
- Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you.
- Research and teaching purposes (all information, medical imaging and clinical photography used will be de-identified)

ALL PATIENTS: PLEASE READ AND TICK

Sending ...

For appointments and enquiries, please phone (02) 8014 4252

Peninsula Orthopaedics Suite 20, Level 7 Northern Beaches Hospital 105 Frenchs Forest Road Frenchs Forest NSW 2086

Mona Vale Rooms Suite 502, 20 Bungan Street Mona Vale NSW 2103

Cremorne Rooms Suite 1, 402 Military Road Cremorne NSW 2090

Northside Orthopaedics Suite 403, Level 4 San Clinic Sydney Adventist Hospital 185 Fox Valley Road Wahroonga NSW 2076

Orthopaedic Associates Level 1, Suite 1 Lakeview Private Hospital 17-19 Solent Circuit Norwest NSW 2153

© 2013-2021 Dr Marcus Chia | Privacy Policy | Disclaimer | Website design: WebInjection