GC Rehab New Patient Form

Patient information and privacy consent form

(Please fill out prior to your first appointment)

Surname(Required)

First Name(Required)

Email Address(Required)

Date(Required)

Home No.

Work No.

Untitled(Required)

Address(Required)

Post Code(Required)

Medicare No.(Required)

Ref #

Expiry Date e.g. MM/YYYY

Health Fund

Membership No.

Veterans Affairs

Pension No.

Next of Kin

Relationship

Phone

Usual GP(Required)

Practice(Required)

I give permission for the release of my medical records to assists with assessment, treatment and management of my medical condition. I also give permission for information to be requested from any medical practitioner, health professional to assist with my medical required.

Memberships & Accreditations:

CONTACT US

Make an appointment

Book your first visit at GC Rehab through the following form, and we will contact you to arrange a date and time.

John Flynn Private Medical Centre
Suite 5A, Medical Centre, 42 Inland Drive, Tugun, QLD 4224

Robina Private Hospital
1 Bayberry Lane, Robina QLD 4226

Gold Coast Private Specialist Suites
Suite 11, 14 Hill Street, Southport, QLD 4215

Privacy Policy