Contact

Alliancern

Alliance Insurance Pathology
ABN 273 1819 5330

Phone: (02)4946 7924
Fax: (02) 4965 9782
Mobile: 0404 511 882

 

 

Mail: PO Box 3259
Valentine
NSW 2280

Online Booking form:

    Name

    D.O.B (dd/mm/yyyy)

    Address

    Suburb

    State

    Post Code

    Mobile Phone

    Home Phone

    Work Phone

    Adviser

    Adviser Phone

    Advisers Email (required)

    Insurer #1

    App no. 1

    Insurer #2

    App no. 2

    Doctors Name

    Doctors Address

    HIV: Yesno

    HbA1C: YesNo

    MBA20 incl HDL/LDL: Yesno

    Standard Health Evaluation/Paramedical: Yesno

    Hepatitis B / Hepatitis C Yesno

    Blood Pressure x 3: Yesno

    Full Blood Count: Yesno

    Resting ECG: Yesno

    PSA: Yesno

    Quick Check / Fast Check: Yesno

    Serum Cotinine: Yesno

    MSU: Yesno

    Iron studies incl Ferritin:Yesno

    Stress ECG: Yesno

    Stress Echocardiogram: Yesno

    GP Medical: Yesno

    Specialist Medical: Yesno

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