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Book now to be emailed a digital form to complete inclusive of the following:

Title

First Name

Preferred Name

Last Name

Sex

Gender Identity

Pronouns

Date of Birth

Street Address

Suburb

State

Postcode

Email Address

Mobile Phone

Name of General Practitioner

Practice Name

Practice Address

Practice Phone Number

Consent to release of information to General Practitioner

Other third parties details

Consent to release of information to the above third parties

Medicare Card Number

Medicare Card Reference Number

Medicare Card Expiry Date

I consent to the collection, storage and use of this personal information for the purposes of service provision including for reminders of appointments, telehealth purposes, and correspondence to recover cancellation fees in accordance with the relevant privacy, telehealth and cancellation policies to which I agree among all Dr Kristen Lovric's other polices, legislation and any other legal requirements that may apply. 

Signature

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