New Patient Form

City Clinic
Secured Patient Information Form
Please complete all questions.
Date of your appointment

DayMonthYear
City Clinic Location?
32 Jamison St Sydney CBD
Opposite The Met Centre in Jamison
50 King Street Sydney CBD
Next door to CBD Hotel cnr King and York
92 Pitt Street Sydney CBD
Opposite Angel Place in Pitt St.
Gender
Full Name

First NameLast Name
Date of Birth

DayMonthYear
Home Address

Street Address

Street Address Line 2

Suburb / CityState

PostcodeCountry
Mobile Number
My Personal E-mail
Occupation
Employer?
You may be entitled to a corporate rate on most City Clinic services. Please provide your work e-mail address below which will automatically flag your patient file when processing payments.
Please provide your company / business name.
Please provide company / business name
Business E-mail?
Did you know about our Corporate Rate Program?
Would you like us to e-mail you information?
Business Address
Street number, Street, Suburb and Postcode

Select the Health Professional you are seeing
Please select service you have an appointment for
Kathy Harmer

Have you completed a comprehensive health analysis questionaire (HAQ)?

To provide you with quality care, Kathy would like you to complete an HAQ on your present state of health and your medical history after you complete this current form.

The questionnaire will take approximately 20-30 minutes to complete.

Please note all information provided by you is captured on a secured form and is kept strictly confidential between you and your health professional.

We will take you to the HAQ after you complete this form.

Please note: you will be able to bookmark the FAQ and return prior your appointment to complete if you don't have time today.
Kathy Harmer

Have you completed a comprehensive health analysis questionaire (HAQ)?

To provide you with quality care, Kathy would like you to complete an HAQ on your present state of health and your medical history after you complete this current form.

The questionnaire will take approximately 20-30 minutes to complete.

Please note all information provided by you is captured on a secured form and is kept strictly confidential between you and your health professional.

We will take you to the HAQ after you complete this form.

Please note: you will be able to bookmark the FAQ and return prior your appointment to complete if you don't have time today.
Height in cms
Weight in kgs
SMS Appointment Reminders
SMS confirmations and appointment reminders are a free
service provided to help you avoid missing your
appointments and incurring no show fees. Please read
our terms and conditions and our privacy policy.

Thank you CC Admin
In case of emergency contact
Relationship to you
Their best contact number

Area CodePhone Number
Do you have a family GP?
Your Dr's Name and Practice Suburb
How did you find us?
Please provide the name of the Fitness Centre
Please provide the name of the Personal Trainer
Please Provide the Doctors Name and Practice Suburb
If other please tell us
Notes
Preferred method of receiving your receipt.
Receive notifications of updates and new services
By submitting this form you have agreed with City Clinic's privacy policy and terms and conditions.
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