Pathology Form Request

This form is only for patients already known to Dr. Christopher Sia privately.

This form should not be used for patient seen at the Alfred hospital or for new patients.

This form should be used if you have misplaced your form or you did not receive it after your telehealth consultation

If you use this service, a small fee of $20 may be added to your next consultation at the discretion of Dr. Sia.

First Name *

Last Name *

Date of Birth *

Home Address (Postal) *

Email Address *

Mobile Phone Number *

Medicare Number (include IRN/Individual Reference Number) *

GP Name and Name of GP Practice *

Which Clinic do you see Dr. Sia at? *

TelecareParkside SpecialistsWattletree Medical Specialists

I know the tests I require *

YesNo

What tests do you require? *

When do you require the pathology form by? *

I agree that I am an exisiting private patient of Dr Sia. I have checked the information supplied above and verify it is correct. I agree to pay a small fee at next consultation with Dr Sia (at his discretion) for the use of this service. *

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