Patient Registration Form

Title

First name

Last name

Preferred name

Date of birth

Day

Month

Year

Phone number *

Address

Postal Address (if different to street address)

Medicare Number

Ref #

Private Health Fund Name

Member #

DVA #

DVA Card Colour

HCC/ Pension Card Number

HCC/ Pension Card Expiry

Do you consent to SMS reminders?

Yes

How did you hear about us?

Referring Doctor's Name

Referring Doctor's Phone Number

Referring Doctor's Address

Usual GP (if different to above)

Usual GP's Phone Number

Usual GP's Address

Emergency Contact Person's Name

Emergency Contact Person's Phone

Xray / Ultra Sound / MRI Report

Have you had any of these scans done for the issue you are seeing Dr Lin for? Tick all that apply.

Xray

Ultrasound

MRI

Where did you have your scan/s done?

Please attach your scan report/s if you have a copy

Workers Compensation / Third Party Details (if applicable)

Employer Name

Employer Phone

Employer Address

Insurance Company Name

Insurance Contact Person

Insurance Company Address

Date of Injury

Claim #

Insurance Phone

Consent To Collect Patient Information

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in the following ways:

1. Administrative purposes in running our medical practice.

2. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.

3. Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you.

• I understand the reasons why my information must be collected.

• I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me.

• I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.

• I understand that if my information is to be used for any purpose other than the above, my consent will be sought.

• I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.

We use AI technology to support our consultation records. All information shared is securely protected, and the AI is used exclusively to enhance the quality of your care. If you do not consent to this, please let us know before your consult.

Referral Upload

Please attached your referral if you have a copy

Patient Signature & Parent / Guardian if under 18

Signature field is empty.

Name of Parent / Guardian (if under 18)

Date of Birth of Parent / Guardian