New Patient Application Form

This practice believes in providing best practice evidence based care.
We expect patients to adhere to our immunisation and chronic disease management policies.

 

* required fields  
*Salutation:
*Full Name:
*Date of Birth:
*Phone:
*Email address:
*Postal Address:
*Postcode:
 
Other Family Members:  
Name: DOB:
Name: DOB:
Name: DOB:
Name: DOB:
       

Immunisation history up to date     Yes      No

Please bring children's immunisation records to initial consultation.
   
Private Health Fund
   
Pension/Health Care Card No
Expiry
   
Recently moved to Bundaberg    
   
Currently attending a General Practice 
 
   
Comments
   
We will notify you within 24 hours of the result of your application.
 

Alexandra Park Medical Centre

60 Quay Street
Bundaberg Qld 4670

Tel: (07) 4152 5477

We are a small practice and so we take a limited
number of new patients - refer to contact page.