Patient Consent Form

A/Prof Kenneth Ho   A/ Prof. Amanda Wang   Dr Lorraine Pereira
Dr Anna Zheng   Dr Andrew Lin   Dr Mehdi Sahebolamri   Dr Sylvia Lim-Tio

Dear Sir/Madam, If this is your first visit to this practice, would you please complete this form and click submit.
Home Address
DD slash MM slash YYYY
Appointment Notification Channel Preference (please tick one):
By 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.
This field is for validation purposes and should be left unchanged.