New Patient Booking New Patient Booking Home New Patient Booking SALUTATION * —DrMrMrsMsMasterMiss FULL NAME MOBILE NUMBER EMAIL DATE OF BIRTH: WHAT SERVICES WOULD YOU LIKE TO BOOK —Dr. Dorgival Caetano WHICH PATIENT TYPE ARE YOU?* Please note we are a private clinic and do not offer bulk-billing service. —Private patient – MedicarePrivate patient – No MedicareWorkcoverCTPMedico-LegalOthers MAIN PRESENTING PROBLEM:* —Adult ADHDAnxiety DisorderBipolar DisorderChronic painDepressionDrug & AlcoholPTSDIntellectual Disability (Includes ASD)Old Age PsychiatryGeneral Paediatric conditionsDevelopmental Paediatric conditionsWorkcover / CTPMedico-legalOther conditions (please state in the message box below) HOW DID YOU HEAR ABOUT US?* Please select all that apply Referral from GPReferral from SpecialistReferral from PsychologistMedia (e.g. TV, Radio etc.)Google searchGoogle mapGoogle adsWord of mouth UPLOAD YOUR REFERRAL LETTER* A referral letter is compulsory at the time of booking request. This is essential for us to assess the suitability. We only accept PDF (preferred) or JPG. https://www.myadhdcentre.com.au/new-patient-booking/
