New Patient Form

Please fill out the form below.

New Patient Form

First Name

Last Name

Work Phone

Mobile Phone

Date of Birth

Birth Sex

Gender Identity

Pronouns

Address

Country

Address Line 1

Address Line 2

Suburb

State

Postcode

Mailing Address

Country

Address Line 1

Address Line 2

Suburb

State

Postcode

Medicare Number & Expiry Date

Pension Number & Expiry Date

DVA Gold / White (circle) Number & Expiry Date

Health Care Card Number & Expiry Date

Are you of Aboriginal or Torres Strait Islander origin?

Yes

If YES, do you consent to registering for Closing the Gap (CTG) with Medicare?

Yes

ETHNICITY - Please specify your place of birth

Patient Consent

Yes

Consent to use your health information

I have read and understand the information above, and I agree to have my anonymous information included in the studies described.

Allergies

Yes (list below)

List Allergies & Reaction

Parent / Guardian (If the patient is under 16 years of age)

First Name

Last Name

Relationship to Patient

Address

Country

Address Line 1

Address Line 2

Suburb

State

Postcode

Phone

CALL : (03) 5744 3115

EMAIL : receptionymc@ymclinic.net.au

Monday – Friday : 8.30am – 5.30pm

New Patient Form

Please fill out the form below.

Address

Mailing Address

Parent / Guardian (If the patient is under 16 years of age)

Address

Providing our patients with comprehensive clinical care, with a wide variety of medical and procedural services available.

Locations

Quick

29 Hume Street 
Yarrawonga VIC

Hours

Monday – Friday 
8.30am – 5.30pm

Contact us

Send a message

Copyright @ 2026 Yarrawonga Medical Clinic. All rights reserved.

CALL : (03) 5744 3115

EMAIL : receptionymc@ymclinic.net.au

Monday – Friday : 8.30am – 5.30pm

New Patient Form

Please fill out the form below.

Address

Mailing Address

Parent / Guardian (If the patient is under 16 years of age)

Address

Providing our patients with comprehensive clinical care, with a wide variety of medical and procedural services available.

Locations

Quick

29 Hume Street Yarrawonga VIC

Hours

Monday – Friday 8.30am – 5.30pm

Contact us

Send a message

Copyright @ 2026 Yarrawonga Medical Clinic. All rights reserved.

29 Hume Street 
Yarrawonga VIC

Monday – Friday 
8.30am – 5.30pm