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 BOOKINGS FORM
(required for all new bookings)

Do you consent to us contacting you with regards to your appointment using one of your phone numbers listed above?
Yes
No
Do you consent to us contacting you with regards to your appointment using your email?
Yes
No
Date of Birth
Day
Month
Year
Gender Identity
To assist with health initiatives, do you identify as:
Do you require an interpreter?
Multi-line address

If you don't have a Medicare Card, type 'N/A'

Last digit (type N/A if you don't have a Medicare Card)

Type N/A if you don't have Medicare Card

Concession Card Number (if applicable)
Who do you wish to book an appointment with (you can pick more than one)?
Do you consent to us contacting your next of kin regarding your appointments/rescheduling?
Yes
No
A doctor's referral is mandatory if you're wanting to book with one of our doctors
Do you consent for your medical information to be uploaded to My Health Records?
Yes
No
I have read and agree to the practice's privacy policy and give financial consent (you can access our policies and information on our fees on our website www.endometabolic.com.au).
Yes
No

© 2026 ENDOCRINE & METABOLIC CLINIC

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