A/Prof Kenneth Ho A/ Prof. Amanda Wang Dr Lorraine Pereira Dr Anna Zheng Dr Andrew Lin Dr Mehdi Sahebolamri Dr Sylvia Lim-Tio Dr William Yu Dear Sir/Madam, If this is your first visit to this practice, would you please complete this form and click submit.Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title Given Name Family Name Home Address Street Address Address Line 2 City State Post Code Date of Birth DD slash MM slash YYYY Home PhoneMobile PhoneEmail Address Medicare NumberRef (next to name):ExpiryHealth care card (if applicable):ExpiryPension Number (if applicable):ExpiryVeteran Affairs number (if applicable):Private Health Fund (if applicable):Name of General PractitionerGP Suburb of PracticeAppointment Notification Channel Preference (please tick one): Text Message/SMS Email Phone Call Reason for ConsultationUrgency(Required) Within Days – This is Urgent 30 Days or Less up to 3 Months Please note a fee may be charged if you do not keep your appointment without advance notification.Doctor Preference Assoc Prof Ken Ho Assoc Prof Amanda Wang Dr Lorraine Pereira Dr Sylvia Lim-Tio Dr Sylvia Lim-Tio Dr. Anna Zheng Dr Andrew Lin Dr. Mehdi Sahebol-Amri Dr William Yu I do not have any preference Provide 1 or 2 choices or select no preference Language English Mandarin Cantonese Farsi Your Preferred Language for CommunicationBy signing below, you enable this practice to collect relevant and appropriate information about you and your health. From time to time, we may need to obtain or share information with other health providers who may have treated you or may treat you in the future, such as emergency departments, other specialists or your general practitioner. I give my consent to the collection of information and release to third parties for these purposes.Signature(Required)EmailThis field is for validation purposes and should be left unchanged. Δ
