New patients can complete the form below to supply:

New Patient Information and Contact Details

    Personal and Contact Details

    Provide your details to Dr Freeman for a consultation

    Title

    Your postcode

    State

    Medicare, Insurance and Concessions

    Date

    Private Insurance

    Type of Private Health Cover

    Next of Kin

    Why Doctor Freeman?

    If other, please specify

    Your Privacy

    I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information. I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of health care and treatment provided to me. I am aware of my right to access the information collected about me, except in circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances. I understand that if my information is to be used for any other purpose, other than set out as above, further consent from me will need to be obtained. *tick box* I therefore consent to the handling of my information by this practice, for the purpose stated above, subject to any limitations on access or disclosure that I notify this practice of.

    Your details are kept confidential