Patient Registration Form Once you have a confirmed session with Lettita, please complete the patient registration form below. Personal Contact InformationFirst Name *Last Name *Date of Birth *Email *Street Address *Suburb *State *Postcode *Mobile *Home PhoneEmergency Contact DetailsFirst Name *Last Name *Phone *Email *Medicare DetailsMedicare Number *Medicare Reference Number *Expiry Date *Referral DetailsName of Referring DoctorSuburbName of Regular GPSuburbObstetrician Name (if relevant)SuburbAdditional InformationIs there anything else you would like to add?Privacy Statement & Consent FormIn submitting this form, you consent to the collection of personal and referral details and to the storage of these details in The Castlecrag Practice database. This information will not be shared with any party (other than your health professional) without your consent. Your health professional will prepare, store and maintain your clinical records. In doing so, he or she must comply with all relevant privacy laws and follow strict professional codes of conduct. We recommend you speak with your health professional about privacy, confidentiality and any other professionals who may be contacted about your care.Full Legal Name *Signed on *SUBMITPlease do not fill in this field.
