CONFIRMING YOUR APPOINTMENT REQUEST FOR YOUR CHILD *

Child's Name

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Agreement to policies-I have read and agree to the policies explained and advised in the New Patient Information Email and this website including the following: *

I have read the New Patient Information Email sent to me in reply to my Appointment Request. The information provided to me explains how New Patient Appointments will be allocated and managed, how earlier appointments may be offered, and the policies, terms and conditions of booking an appointment and requesting the health care services of my child's provider. These policies include those detailed in the For Patients & Families menu of the website at https://www.paediatricsatburnside.com.au/for-patients-families . I have read and agree to these policies, including the following policies and will indicate this agreement by checking each box:

Privacy

Bookings, Fees & Cancellations

Fee Payment

Respect & Trust

Joint Parental Responsibilities.

Health care consultation to be conducted in booked appointments.

Communication & Contact including

Use of email

Use of SMS alerts

Prescriptions by eScript.

Responsibility to be contactable and advise any changes in contact details.

Confirmation of Request by Parent/guardian *

I have read and understand the matters advised in the New Patient Information Email including the policies, terms and conditions of booking an appointment and seeking the health care services of my child's provider. I now confirm my request for an appointment for my child named above.

First Name

Last Name