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 :  


    (签署前请仔细阅读本同意与协议):

    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 or hospitals.
    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 be 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 consent for AIM Health to submit data to diseases registers to assist with preventative health management (e.g. cervical, breast and bowel screening, etc.) and share de-identified information for quality improvement and clinical audit activities purposes.
    5)I agree that I need to make an appointment to discuss my results, or obtain referrals, prescription, medical certificate, MHCP, EPC, etc.
    6)I understand that AIM Health requires at least 24hrs notice to cancel or reschedule an appointment. Failure to do so may result in a cancellation fee of $40, which needs to be paid within 7 days.
    7)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.
    8)I need to make a longer appointment if I have more than one issue or complex health conditions: e.g. TAC or Workcover (not covered by Medicare), referral for mental health care plan, to allied health providers, EPC referral –as per Medicare / insurance requirements under GP Management, etc.
    9)I agree to the assignment of the Medicare benefit directly to the provider unless other arrangement on the day.

    请在下方签名

    签名日期