Consulting at:
Randwick
Miranda
St Leonards

For Appointments and Enquiries
Phone: 02 9650 4422
Fax: 02 9650 4466
Email:

New Patient Details Form

The form below should ONLY be completed by patients who have an existing appointment with Dr Guy Henry.

* denotes required field

 
Child's Details

 
* Child's Surname:
* Child's Given Name(s):
* Child's Gender:
Male    Female
* Child's Date of Birth:
Address Details:
 
* Street:
* Suburb:
* Postcode:
 
Parent/Guardian Details

 
* Mother/Guardian's Surname:
* Mother/Guardian's Given Name(s):
Father/Partner's Surname:
Father/Partner's Given Name(s):
* Telephone Number (Home):
Telephone Number (Work):
* Mobile Number:
* Email Address:
 
Medicare Card Details (Parent and child must be on the same Medicare card)

 
* Medicare Number:
* Patient Number:
* Expiry Date:
* Parent Name On Card:
* Parent Number On Card:
* Parent Date Of Birth:
 
Health Fund Details

 
Health Fund:
Membership Number:
Patient Number:
Level Of Cover:
(i.e. Hospital or Ancillary)
 
Referring Doctor Details

 
* Referring Doctor:
Provider Number:
* Date Of Referral:
Street:
Suburb:
Postcode:
Telephone Number:
 
Local Doctor Details (if different to Referring Doctor)

 
Local Doctor:
Street:
Suburb:
Postcode:
Telephone Number:
 
* Letters will be sent to both referring and local doctors and may be forwarded to specialists if required unless clearly specified below.
 
I do not wish copies of my child's reports to be sent to anyone other than the referring doctor
I am happy for you to send copies of my child's reports to other specialists or doctors
 

 
Image Verification: Please type the characters you see in the picture.
[ Get a new code ]
 
 
Disclaimer: This web site is not intended as a substitute for your own independent health professional's advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider within your country or place of residency with any questions you may have regarding a medical condition.