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New Patient Registration

All patients with an appointment to see Dr Lancashire for the first time are required to fill in a New Patient Registration Form. You are welcome to submit the information by completing the online form below. Alternatively, you may contact reception to request a copy of the form for return to the practice prior to your appointment. 

Please note: items marked * indicate mandatory fields.

Personal details
Contact details
Please enter phone number with area code included. No spaces please. eg. 0298765432
Please enter phone number with area code included. No spaces please. eg. 0298765432
Please enter your full mobile number. No spaces please. eg. 0412345678
Memberships
10 Digits
1 digit next to cardholder's name
eg. HCF, NIB, Bupa
Emergency contact
Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432
Medical Information
Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432
Including over the counter medications
Drugs or other causes

If there are any other specialists that require clinical information, please fill the information below.

Specialist details