Patient information form - DR EMI KHOO & DR RICHARD LEE

Under the National Privacy Act 1988, we require your consent to collect personal 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 need. Your information is used for

Administrative purposes in running our medical practice
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements
Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you, and also to our medical defence organisations.

Patient details

Title

Please choose

Name

First Name

Last Name

Date of birth

YYYY

Contact details

Address

Please provide the address registered with Medicare

Suburb

Postcode

Home phone number

Mobile phone number

Work phone number

Email Address

We will only send required documents to your email registered in our system

Emergency contact information

Emergency contact name

Emergency contact phone number

Medicare and/or DVA Card details

Medicare number

Reference number

Valid until

Please enter month and year of your Medicare Card expiry in the format mm/yyyy. For example 09/2018

DVA number

Private health insurance details (if applicable)

Name of fund

Membership number

Have you been with your fund for over 12 months?

Yes

Level of cover

Hospital Cover and Extras

Hospital only

Extras only

Referral details

Referring Doctor's name

Practice Address

Please enter the medical practice name of your referring doctor . For example " ABC Medical Centre", " Brisbane ( Suburb)

Medical history

COVID Vaccination Status

Please choose one of the following, patients must wear masks when attending doctor appointments

Please choose one of the following pathology you went for your last blood test

Current Medications

Medical allergy

I have read the information above and understand the reasons why my information must be collected. I aware that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of health care and treatment given to me. 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.

I agreed

I have read the attached billing information and agreed to pay the related fee incurred for the service provided.

Please make sure you have read our billing policy before submit the form.

I have read the billing policy below and agreed with it

Billing policy - Dr Emi Khoo & Dr Richard Lee

收费政策 (腸胃科 - 邱醫生和李醫生)