New Patient Registration Form

Prefix

Surname

Given Name

Preferred_Name

DOB

Weight(kg)

Height (m)

Gender

Address

Home Phone

Work Phone

Mobile

Medicare Number

Card Reference no

Medicare Expiry

Do you have private health insurance with hospital cover

Yes No

Name of fund

Membership number

DVAHeath Card no (if applicable)

DVA Card Colour

Blue Pensioner Concession Card No

Expiry Date

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Email

Emergency Contact Phone

Referring Doctor

Usual Doctor

By sending this form,

* I agree that I am responsible for the payment of all fees to Dr Lip Teh for consultation, surgery or any reports requested on my behalf for medicolegal reasons.

* I acknowledge that I have read and understand the information provided in the practice’s Privacy Policy (available in hard copy upon request). I provide consent for this practice to collect, use and disclose my information as outlined in the policy.

**if provided, your mobile number will be used as your main contact number and for text message appointment reminders (unless you advise us otherwise)