Front Desk — Pre-visit intake

Step 1 of 4

About you

Full name *

Please enter your full name.

Date of birth *

Please enter a valid date of birth.

Phone *

Please enter a contact number.

Email optional

Please enter a valid email address.

Home address *

Please enter your street address.

City *

Please enter your city.

Postcode optional

Step 2 of 4

Insurance and ID

Insurance provider optional

Member ID optional

Group number optional

Photo of your insurance card optional

A clear photo of the front of the card. It saves time at the desk.

Take a photo or choose a file

JPG or PNG, up to 10 MB

Tap to change

Photo of a government ID optional

Passport, national ID, or driving licence.

Take a photo or choose a file

JPG or PNG, up to 10 MB

Tap to change

Step 3 of 4

Your visit

What brings you in? *

A short description in your own words is fine.

Please tell us the reason for your visit.

Allergies optional

Medicines, foods, or anything else. Write "none" if that applies.

Current medications optional

Include the dose if you know it.

Have you been diagnosed with any of these?

Tick any that apply. Leave blank if none.

Step 4 of 4

Consent

Two short confirmations before you submit. Both are required.

Please confirm consent to be treated.

Please acknowledge the privacy notice.

Let us get you checked in before you arrive.

About you

Insurance and ID

Your visit

Consent

You are checked in.