Patient Information

Make an appointment: +612 8382 6971 or +612 8382 6977

Clinical assistance: +614 0048 8792

Send an email:

Send a fax: +612 8382 6978

After hours: +612 9388 1577

If you need to send Dr Stricker the information that will assist in streamlining your case, please complete and send the form below.

1. YOUR DETAILS
Name
Date of Birth
Email
Phone Numbers
Street Address
Suburb and State
Postal Address (if different from above)
Suburb and State

2. NEXT OF KIN
Name
Street Address (if different to above)
Suburb and State
Relationship
Contact Numbers

3. MEDICARE AND HEALTH FUND
Medicare
Private Health Fund

4. FAMILY / REFERRING DOCTOR
Family Doctor
Referring Doctor

5. ALLERGIES AND DRUGS
Please list any allergies you have and any drugs you cannot take. If you have no allergies please write ‘no allergies’.

6. MEDICATIONS
Please list any medications you take and how often (e.g. twice daily) and the dosage

7. PREVIOUS OPERATIONS
Please list any medications you take and how often (e.g. twice daily) and the dosage

8. PRIVACY
* By clicking Submit My Information I agree and consent to the collection, use and disclosure of personal (health) information about me as stated in Dr Phillip Stricker’s Privacy Policy.
* I agree and consent to use of pseudonymised personal (health) information about me, being health information about me but with my name and other direct identifiers removed, for medical research that is conducted in accordance with applicable Australian data privacy laws and medical research rules and requirements, including relevant human ethics approvals.