Patient Registration

Your Details

Title

Given Name

Family Name

Preferred Name

Preferred Pronouns Preferred Pronouns

Date of Birth

Address

Phone

Medicare Card Number

Ref No. (Number next to your name)

Valid To

Do you have Private Health Cover

Yes

Health Fund Name

Health Fund Membership Number

Partner Details

I would like to add my partners details (Fertility Patients Only)

Partners Details

Title

Given Name

Family Name

Preferred Name

Preferred Pronouns Preferred Pronouns

Date of Birth

Address is the same as above

Yes, Same address

No, Different address

Address

Phone

Medicare Card Number

Ref No. (Number next to your name)

Valid To

Do you have Private Health Cover

Yes

Health Fund Name

Health Fund Membership Number

Communication & Information Details

Electronic Premission

I/We hereby consent to email communication between Dr Shree Mane and her practice, including giving permission for electronic transfer of my/our records, including results, correspondence with my doctor who referred me/us, and understands that there are privacy risks involved with this form of communication action.

My Health Record

I/We also give consent to upload information onto My Health Record.

NB / I /We authorise the release of my information to my partner ** (delete if information is not to be passed on to partner.)

Yes

How did you learn about Dr Shree Mane? How did you learn about Dr Shree Mane?

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Dr Shree Mane is a Sydney Obstetrician and Gynaecologist, and Fertility Medicine sub-specialist with 30+ years of experience. She has achieved specialist registration in India, the United Kingdom and Australia.

She consults and operates across Western Sydney and offers Saturday appointments, as well as telehealth bookings.

If you have a question about a condition or treatment, or would like to book an appointment, please contact us and one of our friendly staff members will happily assist you.

Fertility

Gynaecology

Obstetrics

Clinic Information

Patient Registration

Your Details

Partners Details

Communication & Information Details

Dr Shree Mane is a Sydney Obstetrician and Gynaecologist, and Fertility Medicine sub-specialist with 30+ years of experience. She has achieved specialist registration in India, the United Kingdom and Australia.

Services

Clinic Info

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