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Telehealth for the Bush

I am interested in
a telehealth consultation

Simply fill in the form below to get started.

Who is this appointment for?*
- Me
- Someone else
First name*
Last name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of birth*
DD slash MM slash YYYY
Phone*
Email*
Are you:*
- an Existing Patient
- a New Patient
How would you like you to receive your telehealth?*
Do you have a Medicare card?**
- Yes
- No
Medicare number*
What number are you on your Medicare card*
Expiry date*
Year*
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Expiry date
Do you have private health insurance?*
- Yes
- No
Fund name*
Member No.*
To help us arrange an appointment with the most appropriate clinicians for your needs, please complete the following:
Do you identify as Aboriginal and/or Torres Strait Islander?*
- Yes
- No
Would you prefer to see a male or female Nurse Practitioner?*
- Male
- Female
- No Preference
Is the patient a child under 12?*
- Yes
- No
Do you have a mental health concern*
- Yes
- No
Do you have specific aged care needs?*
- Yes
- No
What is the broad nature of the reason for this appointment:
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Name
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Telehealth for the Bush for Medical Professionals

Telehealth for the Bush for Patients

Telehealth for the Bush for Aged Care sector

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