New Patient Registration Form

    Home Address
    Postal Address

    Contact Detail
    Medicare Details

    Drivers License

    Pension or Health Care Card Details

    Personal details

    Stratford Medical Centre and Wheels of Wellness participate in Quality Improvement involving the sending of de-identification information for Health Data. Please inform reception if you do not wish to participate.

    Privacy

    Your medical record is a confidential document. It is always the policy of this practice to maintain the security of personal health information and to ensure that this information is only available to authorised members of staff.

    Please refer to our Privacy Policy located at Reception or via our website.




    Yes

    Do you wish to receive SMS notifications from Stratford Medical Centre?


    Yes

    Yes

    Yes

    Yes

    Yes

    If you request to communicate with us via email, we remind you that this is not encrypted, and we do not send information via this means, without your consent.

    Digital Signature

    Date