James Chiu Registration

English繁體中文简体中文

Title

First Name *

Middle Name

Title 頭銜

First Name 名字 *

Middle Name 中間名字

Title 头衔

First Name 名字 *

Middle Name 中间名字

Surname *

Preferred Name

Surname 姓名 *

Preferred Name 希望被稱呼的名字

Surname 姓 *

Preferred Name 希望被称呼的名字

Gender *

MaleFemale

Date of Birth *

Gender 性別 *

Male 男Female 女

Date of Birth 生日 *

Gender 性别 *

Male 男Female 女

Date of Birth 生日 *

Address *

Address 地址 *

Suburb *

State *

Postcode *

Suburb 郊區 *

State 州 *

Postcode 郵遞區號 *

Suburb 郊区 *

State 州 *

Postcode 邮递区号 *

Mobile Phone

Home Phone *

Mobile Phone 手提電話

Home Phone 住宅電話 *

Mobile Phone 手提电话

Home Phone 住宅电话 *

Email Address *

Email Address 電子郵件地址 *

Email Address 电子邮件地址 *

Medicare Number

Medicare Number 全民醫療保險卡號碼

Medicare Number 全民医疗保险卡号码

Reference Number

Expiry

Reference Number 參考編碼

Expiry 截止日期

Reference Number 参考编码

Expiry 截止日期

Veteran *

YesNo

DVA Number

Veteran 退伍軍人 *

Yes 是No 不是

DVA Number 退伍軍人卡號碼

Veteran 退伍军人 *

Yes 是No 不是

DVA Number 退伍军人卡号码

Health Fund

Membership Number

Health Fund 健康保險公司

Membership Number 健康保險會員號碼

Health Fund 健康保险公司

Membership Number 健康保险会员号码

Under 18 years of age

Under 18 years of age 是18歲以下

Under 18 years of age 是18岁以下

Parent / Guardian Full Name *

Parent / Guardian DOB *

Parent / Guardian Full Name 父母/監護人姓名 *

Parent / Guardian DOB 父母/監護人生日 *

Parent / Guardian Full Name 父母/监护人姓名 *

Parent / Guardian DOB 父母/监护人生日 *

Parent Medicare Number

Parent Reference Number

Parent Medicare Number 父母/監護人全民醫療保險卡號碼

Parent Reference Number 參考編碼

Parent Medicare Number 父母/监护人全民医疗保险卡号码

Parent Reference Number 参考编码

Referring Doctor

Referring Doctor 轉介醫生

Referring Doctor 转介医生

Name *

Name 姓名 *

Address *

Address 地址 *

Phone Number *

Phone Number 電話 *

Phone Number 电话 *

Family Doctor

Family Doctor 家庭醫生

Family Doctor 家庭医生

Name

Name 姓名

Address

Address 地址

Phone Number

Phone Number 電話

Phone Number 电话

Physiotherapist

Physiotherapist 物理治療師

Physiotherapist 物理治疗师

Name

Name 姓名

Address

Address 地址

Phone Number

Phone Number 電話

Phone Number 电话

Next of Kin Contact

Next of Kin 近親聯絡人

Next of Kin 近亲联络人

Full Name *

Full Name 姓名 *

Relationship *

Contact Number *

Relationship 關係 *

Contact Number 聯繫電話 *

Relationship 关系 *

Contact Number 联系电话 *

Appointment Reminder, Messages & Emails

門診預約提醒、留言＆電子郵件

门诊预约提醒、留言＆电子邮件

Please advise the front desk staff if you do not wish to receive SMS reminders, or any other message or emails.

Please advise the front desk staff if you do not wish to receive SMS reminders, or any other message or emails.
如果您不希望收到短信提醒或任何其他留言或電子郵件，請通知前台工作人員。

Please advise the front desk staff if you do not wish to receive SMS reminders, or any other message or emails.
如果您不希望收到短信提醒或任何其他留言或电子邮件，请通知前台工作人员。

I consent to receive SMS reminders, messages and emails. *

YesNo

I consent to receive SMS reminders, messages and emails.
我同意收到短信提醒、留言或電子郵件 *

Yes 同意No 不同意

I consent to receive SMS reminders, messages and emails.
我同意收到短信提醒、留言或电子邮件。 *

Yes 同意No 不同意

Privacy Policy

隱私條約

I understand that this practice handles personal information in accordance with the National Privacy Principles enshrined in the Privacy Act 1988 (Commonwealth) and as outlined in the Privacy Statement.
年的隱私法(Commonwealth)所規定的國家隱私法則與診所隱私聲明原則來處理私人資訊。

YesNo

I consent to the handling of my information by this practice for the purpose of providing quality health care, administrative billing purposes and communication with other treating allied health professionals e.g. physiotherapist.
我同意此診所為了以提供優質的醫療保健、費用文書管理和與其他合作治療的專業醫療人士溝通之目的來處理我的資訊，例如物理治療師等。 *

Yes 同意No 不同意

I consent to the handling of my information by this practice for the purpose of providing quality health care, administrative billing purposes and communication with other treating allied health professionals e.g. physiotherapist.
我同意此诊所为了以提供优质的医疗保健、费用文书管理和与其他合作治疗的专业医疗人士沟通之目的来处理我的资讯，例如物理治疗师等。 *

Yes 同意No 不同意

I also give permission for medical information to be obtained from any other source in order to help with my treatment. *

YesNo

I also give permission for medical information to be obtained from any other source in order to help with my treatment.
我同時也允許此診所為了協助我的治療之目的，而從其他出處取得我的醫療紀錄。 *

Yes 同意No 不同意

I also give permission for medical information to be obtained from any other source in order to help with my treatment.
我同时也允许此诊所为了协助我的治疗之目的，而从其他出处取得我的医疗纪录。 *

Yes 同意No 不同意

Payment Policy

付款條約

I understand that this practice accepts bank transfer, Visa, MasterCard, and bank cheque only (personal cheque and Amex are NOT accepted). Full payment for the consultation is required at the time of consultation. Outstanding accounts may be referred to a debt collecting service.
我理解此診所只接受銀行轉帳、Visa、 MasterCard 與銀行支票 (診所是不接受個人支票與 Amex 的)。諮詢門診費用需要當天全額支付。未清帳款有可能會被轉教給收債服務。

I understand that this practice accepts bank transfer, Visa, MasterCard, and bank cheque only (personal cheque and Amex are NOT accepted). Full payment for the consultation is required at the time of consultation. Outstanding accounts may be referred to a debt collecting service.
我理解此诊所只接受银行转帐、Visa、 MasterCard 与银行支票 (诊所是不接受个人支票与 Amex 的)。咨询门诊费用需要当天全额支付。未清帐款有可能会被转教给收债服务。

I consent to the payment policy. *

YesNo

I consent to the payment policy.
我同意付款條約。 *

Yes 同意No 不同意

I consent to the payment policy.
我同意付款条约。 *

Yes 同意No 不同意

Electronically signed by 電子簽名

Electronically signed by 电子签名

Electronically signed by

Draw signature|Type signatureClear

提交