Doctor's name: This is your Doctor's first and last name.
Address: This is the street address of your Doctor's practice.
City, town, or suburb: This is the city, town or suburb of your Doctor's practice.
State: Please make a selection from the dropdown list.
Postcode: This is the postcode of the suburb where you live and must be a valid Australian postcode. Postcodes can be found in the back of the Telstra White Pages.
Date of last consultation: Enter the date of your last consultation in the format dd/mm/yyyy.
Reason for visit: Enter the reason for your last consultation.
Result of visit: Enter the result of your last consultation.