Sam Chia Registration

Thank you for choosing Dr Sam Chia and we look forward to seeing you soon. Prior to your first visit, please go through the following checklist:

1. Check your appointment location– Frenchs Forest, Mona Vale, Barangaroo or Elizabeth St (see www.drsamchia.com.au for more information regarding directions and parking).

2. Bring any relevant imaging or reports- Dr Chia can generally access digital images from Healthcare Imaging, PRP, i-Med, Medscan, Castlereagh Imaging, North Shore Private Radiology and Mater Radiology (Alfred Imaging). If your imaging provider is not on the above list please bring hard copies of the scans (not just the report) or a CD.

Title *

First Name *

Surname *

Preferred NameIf different from First Name

Date of Birth *

Occupation *

Address *

Suburb *

State *

Postcode *

Email Address *This address will also receive a copy of your registration

Mobile

Home Phone

Please enter at least one phone number to continue