New Patients - Lifeline Medical Centre

New Patient Registration Form

We are committed to providing our patients with the best care. To do this, it is essential that your health record is kept up to date and accurate. Please assist us by completing the following pages:

*This information is completely voluntary and may help individualise and enhance your care.

If you prefer to print & fill this form out manually, then please download it here:

This clinic does NOT prescribe opioids, benzos or any other drugs of addiction to new patients.

"*" indicates required fields

Step 1 of 6

Title*

Name*

First Last

Sex*

Date of Birth*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Mailing Address (if different to above)

Mailing Address (if different to above)

Yes

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Home Phone

Mobile Phone*

Email*

Occupation

Declaration

Are you under the age of 16?

Are you under the age of 16?*

Yes

Parents please sign this form on behalf of your children under the age of 16.

Parent or Guardian Signature*

Date*

Patient Signature

Signature*

Date*

Name

This field is for validation purposes and should be left unchanged.