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First Name (required)

Last Name (required)

Gender
MaleFemaleOther

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?
YesNo

Indigenous Status - Ethnicity

Occupation
Health CareAged CareSchoolChild CareDisability CareOther

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)
YesNo

Additional Special Needs:
Hearing impairedVisually ImpairedNo 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?
YesNo

If so which country?

Have you had any contact with confirmed COVID case within 14 days before onset of symptoms?
YesNo

Have you already had a COVID-19 swab test?
YesNo

Are there family members or household contacts that need to be assessed? (they will need to apply separately)?
YesNo

Please select any symptoms you may have from the following:
HeadacheTirednessSore ThroatRunny NoseJoint PainShortness of BreathCoughOther

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 consentI do not consent

About Us

Riverstone Family Medical Practice is located at 71 Garfield Road East, in the heart of Riverstone. We are just a few minutes walk from Riverstone Railway Station. If you are coming by car, there is ample street parking nearby.

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