Medcare | Mail Your Doctor

Personal Details
First Name*	Last Name	Already Registered in Medcare? Enter Pin Number
Nationality	Gender* Male Female	Age
Contact Details
Telephone	Mobile	E-mail Address*

Additional Information
Name of requesting individual (if different than patient)	Parent name (if patient is a minor)
To whom the question is addressed
Select a Department*	Select a Doctor (Select a Department)

Case Summary / Symptoms (Medical Concern)*

Date of onset or duration of current problem

Is the patient's illness or injury
Work Related? Auto Accident? Other?

Attach X Rays (in jpeg format) or Medical Reports
(jpeg scans or MS Word / PDF Format)

Authorisation

Verification Code*

*Required Fields

Additional Information
Insurance Company name and plan	Insurance ID number
Name of requesting individual (if different than patient)	Parent name (if patient is a minor)
Appointment Details
Select a Department*	Select a Doctor (Select a Department)
Preferred Date 1*dd/mm/yyyy	Preferred Time 1*
Preferred Date 2 dd/mm/yyyy	Preferred Time 2