New Patient Registration Form

Name

Date of Birth

Gender

Street Address

City

State/Province

ZIP / Postal Code

Phone

Email Address

Medicare Number

Medicare Expiry

Private Health:

Next of Kin/Emergency Contact:

Next of Kin Relationship:

Next of Kin Phone

Referrig GP Name:

Referrig GP Address:

Referrig GP Phone:

Confidentiality and Communication

Dr Anupam Pokharel is a consultant psychiatrist providing assessment and treatment for mental health conditions. Information discussed during consultations is confidential except in situations where disclosure is required by law or where there is serious risk of harm to yourself or others. Letters may be sent to your referring doctor regarding your treatment unless you request otherwise.

Do you consent report/letters sent to referring GP? *

I agree with the privacy policy and terms and conditions. I understand that my personal information will be collected and stored for the purpose of providing psychiatric care. *

Please refer to the website for the privacy policy and terms and conditions.

I consent to participate in psychiatric consultations via telehealth where appropriate. *

Appointment Cancellation and No Show

Appointments cancelled with less than 24 hours' notice or no-shows will incur a cancellation fee.

I understand the cancellation policy. *

By typing your name below you confirm that you have read and understood the information above and consent to psychiatric assessment and treatment.

Scroll to Top