Please review our Privacy Statement before filling out the form.

Personal and Health Information Collection Statement

Fairfield Paediatrics (“us”, “we”, “our”) only collect the information we need in order to perform our services (“Services”).

We comply at all times with the Australian Privacy law which regulates how personal information is handled including all your health details which are considered sensitive information (“Personal Sensitive Information”). We will not disclose your Personal Sensitive Information without your consent unless required due to a medical emergency, injury, health risk or similar and we will only do so to a qualified professional who is under the same duty of confidentiality.

You may contact us by writing to the Director of Fairfield Paediatrics, PO Box 221, Fairfield VIC 3078 and have the right to gain access to the information held by Fairfield Paediatrics about you.

Our Privacy Policy on our website contains information on how you may request access to, and correction of, any of the information we hold about you including your Personal Sensitive Information and how you may complain about a breach of your privacy as well as how we will deal with a complaint.

By providing us with this Personal Sensitive Information, you acknowledge and agree that the information you are providing to us is true and correct at the time you are providing it to us. You will notify us with any changes and keep it updated on a regular basis while you are using our Services. You can access your Personal Sensitive Information by request at any time.

We keep your Personal Sensitive Information secure and do not use it for any purposes unrelated to our Services. All our employees and any staff who may have access this personal information are under a strict duty of confidentiality and privacy practices are adhered to. Please note: we securely destroy all your Personal Sensitive Information after your child turns 25 or 7 years from the last point of contact (whichever is the longer) if you have ceased using our Services.

From time to time, we may use your Personal Sensitive Information to contact you in relation to information on our Services. You can unsubscribe at any time or advise us that you withdraw your consent to these specific uses and be removed from any further marketing or information we may send.

Important Note: Our Services are not a substitute for medical attention, treatment, examination, advice or diagnosis. You are responsible for consulting a doctor before commencing any new regimes or alterations to your diet or health. You take full responsibility for making the informed decision to use our Services. You hereby agree to irrevocably release and waive any claims you may have now or in the future against us.

So that we can best help your child, please take the time to fill in the questions on of this form, providing as much information as possible.  Preferably, please complete online prior to your child’s appointment or arrive at least 10 minutes before your appointment time to allow the paperwork to be completed.

If you have any questions or concerns prior to your child’s appointment, please do not hesitate to contact us on or phone 1300 755 047.


    Medicare card number

    Medicare reference number

    Medicare expiry date

    Health fund name

    Membership number

    Position on a Card No

    Expiry date

    Indigenous or Torres Strait Islander descent

    Interpreter required

    Please specify language


    Does your child or any accompanying family member require disabled access?

    Please specify the access required

    Are there any custody restrictions applicable to this child? If yes, please discuss this with Dr. Coates.


    Medicare card number

    Medicare reference number

    Medicare expiry date


    Alternative Contact (friend or relative, eg to take a message)

    Where did you hear about Fairfield Paediatrics?

    GoogleFacebookGPWord of mouthPrevious patient (child or sibling)Maternal and Child Health nurseHospitalOther