Planning your appointment

In order to make your appointment as efficient and effective as possible you may like to complete this form prior to seeing your doctor.

Please identify any issues you would like to discuss with the doctor.

Depending on time constraints, not all of these may be able to be discussed in this consultation. We will start with the most important issue.

First Name *

Last Name *

Date of Birth *

Email: *

Issues:

Please put the most important issue first

Issue 1

Issue 2

Issue 3

Referrals required:

(Please allow 5 minutes per standard referral. Referrals for Mental Health Care Plans required a dedicated 30-minute consultation)

Referral 1:

Referral 2

Referral 3

Prescriptions required:

(Please allow time for the doctor to review the appropriateness and effectiveness of your medication)

Prescription 1

Prescription 2

Prescription 3

Prescription 4

Prescription 5

Prescription 6

As part of our commitment to your health and wellbeing, we would like to remind you of some important preventative health activities.

Are you due for:

Cervical Screen Test (Pap Smear)ColonoscopySkin Cancer CheckMammogramBone DensityFaecal Occult Blood Test (Bowel Cancer Screening Test)Immunisations - such as 10 yearly Tetanus booster after age 50Medication ReviewChronic Disease Management PlanHealth AssessmentOther - please specify below

Other - please specify

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