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.

Name

Title Given Name Family Name

Home Address

Street Address Address Line 2 City State Post Code

Date of Birth

Home Phone

Mobile Phone

Email Address

Medicare Number

Ref (next to name):

Expiry

Health care card (if applicable):

Expiry

Pension Number (if applicable):

Expiry

Veteran Affairs number (if applicable):

Private Health Fund (if applicable):

Name of General Practitioner

GP Suburb of Practice

Appointment Notification Channel Preference (please tick one):

Text Message/SMS

Phone Call

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.

Signature(Required)

Name

This field is for validation purposes and should be left unchanged.