* Required Fields

    FemaleMaleGender Diverse

    YesNo

    Current GP

    YesNo

    Identity Document

    Please upload a copy of your valid ID document. e.g. Passport, Drivers License, Birth Cert etc.

    Agreement and Acknowledgement

    NB. Parent or Caregiver to sign if you are under 16 years

    • I acknowledge that I have reviewed the relevant fees displayed/provided to me for services rendered.

    • I acknowledge to pay for all consultation and service costs at the time of my appointment or request for service.

    • I acknowledge any payment not completed at the time of my appointment or request for service will incur an additional $15.00 administration fee.

    • If unpaid after 30 days from the date of service, my account may be placed in the hands of a debt collection agency and all costs associated with this will be my responsibility to pay.

    Your Signature: