(02) 9627 0600
info@rfmp.com.au
2014 GENERAL PRACTICE OF THE YEAR
Online Appointment
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First Name (required)
Last Name (required)
Gender
Male
Female
Other
Date of Birth (required)
Street number and name (required)
Suburb (required)
Post Code (required)
Phone Number (mobile if you have one) (required)
Email (required)
The clinic is free to all who attend. However, if you do not have a medicare card, the pathology will be at cost to you.
Medicare Number
Medicare Reference Number (the number to the left of your name on the card)
Medicare Expiry Date
Preferred Language (required)
Do you need an interpreter?
Yes
No
Indigenous Status - Ethnicity
Occupation
Health Care
Aged Care
School
Child Care
Disability Care
Other
If Other, please specify
Next of Kin: Name (required)
Next of Kin: Email (required)
Next of Kin: Phone No. (required)
Are they being tested as well? (required)
Yes
No
Additional Special Needs:
Hearing impaired
Visually Impaired
No Car - WALK IN
Your usual GP's name
Your GP's address
Your GP's Telephone Number
Have you travelled overseas within the last 14 days before symptoms onset?
Yes
No
If so which country?
Have you had any contact with confirmed COVID case within 14 days before onset of symptoms?
Yes
No
Have you already had a COVID-19 swab test?
Yes
No
Are there family members or household contacts that need to be assessed? (they will need to apply separately)?
Yes
No
Please select any symptoms you may have from the following:
Headache
Tiredness
Sore Throat
Runny Nose
Joint Pain
Shortness of Breath
Cough
Other
If Other, please specify
Your message
I have read the
Privacy (APP5) Collection Notice
(shown below) and consent to the operator of the Riverstone GP Respiratory Clinic providing my personal information to the Department, and to the relevant Primary Health Network, for the purposes described. I understand that I can contact the Department if I wish to withdraw my consent and, if I do so, the Department will not make any future use or disclosure of my personal information unless it is otherwise authorised or permitted by the Privacy Act 1988 (Cth).
I consent
I do not consent
Online Appointment