Booking Details

Service:

Dose:

Appointment Date:

Appointment Time:

Pharmacy Name:

Location:

Phone Number:

Booking Reference Number:

Please present your booking reference number at your appointment
If you need to cancel, please contact

Your Details

First Name:

Last Name:

Phone:

Email:

Gender:

You have been sent an email with these details. You will also receive a reminder 24 hours before your booking.

Confirm Booking Details:

Booking Details:

Service:

Appointment Date:

Appointment Time:

Pharmacy Name:

Location:

Phone Number:

Enter Your Details:

First Name*

Last Name*

Mobile*

Email*

Gender*

Date of birth*

Street*

Suburb*

State*

Postcode*

Reason for consultation*

What are you experiencing with your health? Provide information to help with the consultation.

Relevant background information*

Include information relevant to your situation e.g. medication you are on, recent health issues, allergies etc.

I am consenting as a substitute decision-maker (e.g. carer) on behalf of the patient

Name of substitute decision-maker*

Consent to pilot clinical service and costs*

If applicable, I agree to participate in the Queensland Community Pharmacy Chronic Conditions Management Pilot and understand the scope of the clinical service. I consent to paying the pilot consultation fee and any costs associated with the service. I understand that if I decide not to proceed with receiving some part of a service, I may still be required to pay for services that have already been provided. I understand that my pharmacist will inform me if this is applicable to my situation.

Consent to pilot evaluation*

If applicable, I consent to participating in the evaluation of the Queensland Community Pharmacy Chronic Conditions Management Pilot and agree to being contacted to participate in surveys about the pilot. I consent to my administrative health service data being analysed for evaluation purposes. I understand that my pharmacist will inform me if this is applicable to my situation.

Organisation Code*

Division*

Employee Status*

Participant ID*

Service selection*

I have read and accept the Guild Corporate Health Privacy Policy. I give consent for the pharmacy to provide my personal information to my employer for reconciliation and program management purposes. *

I have read and accept the MedAdvisor Terms and Conditions and Privacy Policy. *

This program closes at 4pm AEST July 31st. Do not book a vaccination after this date/time.

Security Question*