Hyde Park Medical Centre

Online Patient Registration

Ground Floor, Shop 1, 175 Liverpool St

Sydney, NSW 2000

Phone : (02) 9283 1234

Fax : (02) 9283 0303

Email : hpmc175@optusnet.com.au

 
Online Patient Registration - Registration Guide
Term and Condition:

1. Hyde Park Medical Centre - Online Patient Registration only support for Australia Resident Address.
2. A confirmation notification message will be sent to your mobile and/or email upon successful entry.
3. Alternately, you can fill in this patient registration form upon your first visit, please call 9283-1234 for phone booking.

("*") indicate input required

PATIENT INFORMATION
*Surname: *First Name: Middle Name:
*Date of Birth:
(dd/mm/yyyy e.g. 25/09/1997)
/ / *Gender: *Title:
*Street Address:
*Suburb: *State: *Postcode:
Home Phone:
(e.g. 92831234)
Work Phone:
(e.g. 92831234)
*Mobile:
(e.g. 0466915511)
Email Address:

*Ethnicity:
EMERGENCY CONTACT
*Surname: *First Name: *Title:
*Relationship: *Contact No:
(e.g. 0466915511)
Alt. Contact No:
(e.g. 92831234)
MEDICARE / CONCESSION CARDS / PRIVATE INSURANCE
Medicare No:
e.g.1234 12345 1
Ref No: Valid To:
(MM/YYYY e.g. 12/2015)
/
Do you have a Veteran Affairs (DVA) ? If yes, File Number: Type:
Do you have any other Australian Government / Concession Card? (Student Concession excluded) If yes, please provide detail below:-
Type: Membership No: Valid To:
(dd/mm/yyyy e.g. 25/09/2018)
/ /
Do you have any OSHC Insurance? If yes, please provide detail below:-
Insurance Name: Membership No: Expire Date:
(dd/mm/yyyy e.g. 25/09/2018)
/ /