Patient Registration Details

Preferred Salutation/Title

Ms

Mrs

Mr

Dr

Other

Preferred Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Birth Sex *

Assigned Female

Assigned Male

Not Applicable

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Referring Doctor Details *

General Practitioner

Specialist

Other

Electronic Communication

Dr. Nipu makes use of SMS and email communication to confirm and remind patients of their appointments, surgeries, recalls etc.

I DO want to receive SMS communication

I DO want to receive email communication

Account Type

Private

Others

Set the same as Home Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Financial Consent *

All patients are required to pay the consultation fee on the day of consultation with Dr Jayatilleke.

I agree to the financial consent statement above

Privacy Consent *

In order to provide healthcare to you, it is necessary for Dr Jayatilleke and her staff to collect personal information about yourself, your medical history and your family’s medical history. This information may be disclosed to other 3rd parties involved in treating you. Our Privacy Policy is available from our staff, should you wish to understand more about how we collect and disclose health information. I acknowledge the fee displayed at the practice and agree to the payment terms. I give consent for the collection, use and disclosure of health information (as per the practice Privacy Policy.)

I agree to the privacy consent statement above