Patient Registration Please complete the online form below, or download a copy to complete and bring to your appointment. PATIENT INFORMATIONName(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Middle Last Date of birth(Required)Sex (assigned at birth)(Required)Preferred namePronounsIs the patient under 18 years old?(Required) Yes No Guardian / Parent Name First Last Guardian / Parent D.O.BGuardian / Parent contact numberGuardian / Parent Medicare numberRef numberExpiryGuardian / Parent EmailResidential Address Street Address Suburb Postcode Is your postal address different to your residential address?(Required) Yes No Postal Address Street Address Suburb Postcode Email AddressHome phoneWork phoneMobile phoneMobile for texting? Yes No Health Funds & InsuranceMedicare NumberReference No.Expiry DatePrivate Health Fund NameMembership NumberDVA/Veteran NumberType Gold White Orange Expiry DateHealth Card NumberExpiry DatePension NumberExpiry DateReferrer / General Practitioner detailsReferring Dr Name DrDr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Practice namePractice Address Street Address Suburb Postcode Is the Referring Dr different to your usual GP? Yes No GP Name DrDr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last GP Practice nameGP Practice Address Street Address Suburb Postcode Emergency ContactFull NameRelationshipRelationship Contact NumberContact NumberFee PolicyThere is a consultation fee and this is payable on the day of consultation. Failure to attend/ missed appointments, without prior contact to the office will incur a fee. By signing this form, you are agreeing to the fee policy. Surgical fees are discussed only if surgeon has recommended a procedure.Privacy StatementProfessor Leon Lai complies with the Health Records Act 2001 (Vic) and the Privacy Act 1988 (Cth) in collecting, storing, and sharing your personal and health information. Your information is used to provide medical care, manage appointments, communicate with other healthcare providers, and meet legal and billing obligations. It may be shared with your general practitioner, hospitals, radiologists, or other specialists directly involved in your care. All information is securely stored and handled in accordance with the Health Privacy Principles and Australian Privacy Principles. You may request access to or correction of your records at any time. For more information, please contact our practice or visit www.hcc.vic.gov.au.Patient ConsentI consent to the collection, use, and disclosure of my personal and health information by the practice of Professor Leon Lai for the purposes described above, in accordance with the Health Records Act 2001 (Vic) and the Privacy Act 1988 (Cth).Patient Name(Required) First Last Signature(Required)Your NameYour NameYour NameYour NameDate(Required) CAPTCHAUntitledUntitledUntitledNumberDate Month Day Year UntitledUntitled
