TELEHEALTH REQUEST FORM (mandatory for all requests for calls, video consultations, medication repeat requests or minor enquires of existing patients)

First name*

Middle name

Last name*

Mobile phone*

Do you consent to us contacting you with regards to your appointment using your phone number listed above?*

Yes

No

Email

Date of Birth*

Day

Month

Year

Who do you wish to book a telehealth appointment with?*

Dr Ramy Bishay (Endocrinologist & Bariatric Physician)

Dr Santhi Chalasani (Endocrinologist)

Dr Mehdi Sahebolamri (Endocrinologist)

Dr Mawson Wang (Endocrinologist)

Dr Tavleen Kaur (Endocrinologist)

A/Prof Renuka Shanmugalingam (Renal Physician & Obstetric Physician)

Mr Tony Saba (Certified Diabetes Educator)

Dr Tomas Megalaa (Senior Podiatrist)

Mrs Ban Hasanin (Dietitian)

Mr Michael Malek (Physiotherapist)

Unsure

Do you consent to us contacting your next of kin regarding this telehealth request if required?*

Yes

No

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 (you can access our policies at www.endometabolic.com.au).*

Yes

No

Do you consent to assign your medicare benefit, for the purposes of bulk-billing your telehealth appointment, to the treating doctor/clinician?*

Yes

No

Date

Day

Month

Year

Signature*

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