Please complete this form in its entirety, and tick the boxes to show that you have read and consented to the provision of your personal information and the fee agreement. This information is essential for making your appointment.
* Please note that all information transmitted from our patients to our clinic via the website is encrypted and a dedicated email address is used to receive electronic communications.
The form can be either completed online and sent electronically, or downloaded and printed out for manual completion and return by email, post or fax to The Lung Health Clinic.
To download this form for manual completion, please click here.
This is a private practice | payment of accounts is required on the day of the consultation
Please ensure your bank account details are lodged with Medicare as they now require these details as of July 2016.