To Make an Appointment

Consultations are by appointment and require a GP or Specialist referral letter to be emailed in advance to This email address is being protected from spambots. You need JavaScript enabled to view it.

Please complete the form below and attach a copy of your referral.

Forms

MLSS Patient Registration form

Existing Patients or for further information

Please contact our reception staff on 9421 0177 or via email This email address is being protected from spambots. You need JavaScript enabled to view it.

Frequently Asked Questions

New Patient Registration Form

Surname(*)

Please supply your Surname

Date of Birth(*)

Please supply your Date of Birth

Given Names(*)

Please supply your Given Names

Preferred Name

Please supply your Preferred Name

Address(*)

Please supply your address

City(*)

Please supply your city

Postcode(*)

Please supply your Postcode

Contact Numbers

Telephone(*)

Please supply your Telephone

Mobile(*)

Please supply your Mobile

Email(*)

Please supply your Email

Other Details

Referring Doctor(*)

Please supply the name of your Referring Doctor

Regular GP(*)

Please supply the name of your Regular GP

GP's Address(*)

Please supply the address of your Regular GP

GP’s telephone number(*)

Please supply the contact number for your regular GP

Referral provided by GP or Doctor

Invalid Input

Are you are pensioner(*)

YesNo

Please let us know if you are a pensioner

Type(*)

What Type of Pensioner are you

Number

What is your Pensioner Number

Medicare Number(*)

Please supply your Medicare Number

Medicare Ref No(*)

Please supply your Ref Number

Exp Date(*)

Please supply your Medicare Exp Date

Private Health Insurance(*)

YesNo

Do you have Private Health Insurance

Fund(*)

Please supply your Fund name

Membership Number(*)

Please supply your Membership Number

Emergency Contact Person(*)

Emergency Contact Person Name

Relationship(*)

Relationship

Emergency Contact Number(*)

Emergency Contact Number

Is this visit compensation related (WorkCover/TAC)(*)

YesNo

Is this visit compensation related (WorkCover/TAC)

WorkCover OR TAC(*)

WorkCoverTAC

Is it WorkCover or TAC

Claim Number(*)

Claim Number

Terms & Conditions

I hereby give express permission to the staff and associates of Dr Piers Canty to receive and supply personal medical information from or to other medical practitioners on my behalf. I/We acknowledge that I/we are wholly responsible to arrange any further appointments to discuss test results conducted by Dr Canty on our behalf. Please note that your private information will be protected under the Commonwealth Health Private Act 2001.

(*)

I agree to these terms and conditions

Please read the above terms and agree

Signed(*)

Sign Above

please sign and agree to the Terms and Conditions

Forms

Existing Patients or for further information

New Patient Registration Form

Contact Numbers

Other Details

Terms & Conditions