My Health Online

Registration form for My Health Online

Last Updated: 21/02/2023

Personal Details

Please complete all sections so we can register you for My Health Online

Full Name *

Date of Birth *

Address *

e-mail *

Home Telephone Number *

Mobile Number *

Communication Preference

I consent to text notifications being sent to me about appointment reminders, health promotion information, cancellation of clinics and information/changes in service provision. *

Yes No

I consent to e-mail notifications being sent to me about appointment reminders, health promotion information, cancellation of clinics and information/changes in service provision. *

Yes No

Confirmation

I confirm I am sumbitting this form for myself, not on behalf of another person *

Yes No

Signature (typed name) *

Date *

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My Health Online

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