Patient Registration - Avonlea Clinic

We require a referral from your GP and any relevant results before an appointment can be made.

Once this has been received our reception staff will contact you to arrange an appointment.

Doctor to consult with*
Title
Name*
First Surname
Gender
Preferred Pronouns
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home phone
Work phone
Mobile phone*
Consent to be contacted via SMS*
Email*
Consent to be contacted via email*
Have you been fully vaccinated against COVID-19?*
- Yes
- No
Do you agree to have a medical student sit in on your consultation?*
- Yes
- No