注册表


    医保卡号码 :
    医保卡 Ref No. :  


    优惠卡(Concession Card) :  
    优惠卡类别 :  


    如果您没有医保卡
    私人保险公司 :  
    保险类型 :  
    保险号码(membership / Policy No) :  


    称呼:       性别 :  
    姓(Surname) :   名(First Name) :  

    出生日期 :  

    居住地址(如有,请包括门牌号):  
    区(Suburb) :  
    邮编(Post Code) :  
    手机号码 :  
    家庭电话 :  
    电子邮箱 :  


    文化背景

    出生国家 :  

    语言 :  


    直系亲属
    姓名 :  
    关系 :  
    手机 :  


    紧急联系人 (如果与直系亲属不同)
    姓名 :  
    关系 :  
    手机 :  


    (Please read this consent and agreement carefully prior to sign):
    1) I understand that collecting my personal information and medical history is required to ensure high quality healthcare, accurate Medicare/Insurance billing and referral to other specialists.
    2) I shall inform AIM Health if there are any changes to my contact details, such as address and phone/mobile number. If I am unable to contacted, I understand that I am responsible for any associated consequences.
    3) I consent for AIM Health to send me reminders via SMS, phone call, letter or email.
    4) I agree that I need to make an appointment to discuss my result, and/or, obtaining a referral, prescription, medical certificate, mental health care plan or EPC, etc.
    5)I understand that AIM Health requires at least 24 hours’ notice to cancel or reschedule an appointment. Failure to do so may result in a cancellation fee of $30, which needs to be paid within 7 days.
    6) I am aware that there will be an administration fee to transfer/obtain my medical records, which needs to be paid upfront, as per the Australian Health Record Regulation.
    7) I need to make a longer appointment if I have more than one issue or complex health conditions.

    请在下方签名

    Signed on :