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Patient Registration

Please complete this registration form before your initial consultation with Dr Doherty. Completing it in advance helps us keep appointments running smoothly and on time.

Your information is confidential and handled in accordance with our Privacy Policy. In an emergency call Triple Zero (000) — this form is not for urgent medical concerns.
Patient Details
Address
Contact
Referral & GP
Medicare & Private Health
Occupation & Next of Kin
How did you first find out about us?
Health Questionnaire
Personal History

Please tick any that apply to you.

If your personal details or medical condition change in future, please advise us.

Consent

Please indicate your preferences below. You may change any of these at any time.

I give permission for use of an AI scribe to take notes during my consultations with Dr Doherty.

I give permission for de-identified clinical information to be used for research purposes.

I give permission for clinical photographs to be taken as part of my consultation.

My clinical photographs may be used for medical education (doctors, nurses, medical students only).

My clinical photographs may be used for public education purposes.

My consultation notes may be used in communication with other health professionals involved in my care.

Referral

PDF, photo (JPG/PNG/HEIC) or Word document. Maximum 10 MB. You can also bring the original to your consultation.

Acknowledgement

Sign above using your mouse, finger or stylus. Your typed name below serves as a secondary confirmation.

If completing on behalf of a minor or dependent, please sign and type the parent or guardian's name.