Patient registration form

The first step in registering as a patient with us.
This form captures your general and medical information.

Please fill out all the information below and submit to Intus before your appointment. The form will take approximately 10 minutes to complete.

IMPORTANT:

  • Please take time to gather all the required information before filling this form out online. This includes your insurance information, contact information for your referring GP & your current medications.
  • Your information will get sent directly through to our medical records and will not be stored anywhere else.
  • Items marked * indicate mandatory fields.
  • On successful completion you will see a successful submission message and receive an acknowledgment email. If you do not see this, your form has not been submitted. 
  • If you are experiencing issues completing your Registration Form online, please contact (03) 977 5977 and one of our support staff will be happy to assist you.

Next of Kin/Emergency Contact Details