{"id":429,"date":"2022-01-12T11:24:56","date_gmt":"2022-01-12T11:24:56","guid":{"rendered":"https:\/\/aimhealth.com.au\/?page_id=429"},"modified":"2022-01-12T12:15:20","modified_gmt":"2022-01-12T12:15:20","slug":"cnpatientregform","status":"publish","type":"page","link":"https:\/\/aimhealth.com.au\/zh\/cnpatientregform\/","title":{"rendered":"\u6ce8\u518c\u8868"},"content":{"rendered":"<div class=\"wp-block-contact-form-7-contact-form-selector\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f428-o1\" lang=\"en-AU\" dir=\"ltr\" data-wpcf7-id=\"428\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/zh\/wp-json\/wp\/v2\/pages\/429#wpcf7-f428-o1\" method=\"post\" class=\"wpcf7-form init wpcf7-acceptance-as-validation\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\" data-trp-original-action=\"\/zh\/wp-json\/wp\/v2\/pages\/429#wpcf7-f428-o1\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"428\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.7\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_AU\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f428-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<!-- Medicare section -->\n<hr color=\"#7FFFD4\" style=\"height:10px\" \/>\n<p><b>\u533b\u4fdd\u5361\u53f7\u7801<\/b> :<span class=\"wpcf7-form-control-wrap\" data-name=\"medicare-no\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"medicare-no\" \/><\/span><br \/>\n<b>\u533b\u4fdd\u5361 Ref No.<\/b> : &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"medicare-ref-no\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"medicare-ref-no\"><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><\/select><\/span>\n<\/p>\n\n<!-- Concession card -->\n<hr color=\"#7FFFD4\" style=\"height:10px\" \/>\n<p><b>\u4f18\u60e0\u5361\uff08Concession Card) <\/b>: &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"concession-card-no\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"\" value=\"\" type=\"text\" name=\"concession-card-no\" \/><\/span><br \/>\n<b>\u4f18\u60e0\u5361\u7c7b\u522b <\/b>: &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"concession-type\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"concession-type\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Pension\">Pension<\/option><option value=\"Health Care\">Health Care<\/option><option value=\"Senior Health Care\">Senior Health Care<\/option><\/select><\/span>\n<\/p>\n<hr color=\"#7FFFD4\" style=\"height:10px\" \/>\n<p><b><mark>\u5982\u679c\u60a8\u6ca1\u6709\u533b\u4fdd\u5361<\/mark><\/b><br \/>\n<b>\u79c1\u4eba\u4fdd\u9669\u516c\u53f8 <\/b>: &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"private-insurance-company\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"private-insurance-company\" \/><\/span><br \/>\n<b>\u4fdd\u9669\u7c7b\u578b <\/b> : &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-type\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"insurance-type\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"OVHC\">OVHC<\/option><option value=\"OSHC\">OSHC<\/option><\/select><\/span><br \/>\n<b>\u4fdd\u9669\u53f7\u7801\uff08membership \/ Policy No\uff09 <\/b>: &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-policy-no\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"insurance-policy-no\" \/><\/span>\n<\/p>\n<hr color=\"#7FFFD4\" style=\"height:10px\" \/>\n<p><b>\u79f0\u547c<\/b>: &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-title\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"patient-title\"><option value=\"Dr\">Dr<\/option><option value=\"Mrs\">Mrs<\/option><option value=\"Ms\">Ms<\/option><option value=\"Miss\">Miss<\/option><option value=\"Mr\">Mr<\/option><\/select><\/span><b> &#160 &#160 \u6027\u522b <\/b> : &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-sex\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"patient-sex\"><option value=\"Female\">Female<\/option><option value=\"Male\">Male<\/option><option value=\"Others\">Others<\/option><\/select><\/span><br \/>\n<b>\u59d3(Surname) <\/b>: &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-last-name\" \/><\/span><b>\u540d(First Name) <\/b>: &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-first-name\" \/><\/span>\n<\/p>\n<div class=\"content-column full_width\">\n\t<p><b>\u51fa\u751f\u65e5\u671f <\/b> : &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-birth-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"patient-birth-date\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<hr color=\"#7FFFD4\" style=\"height:10px\" \/>\n<p><b>\u5c45\u4f4f\u5730\u5740<\/b>\uff08\u5982\u6709\uff0c\u8bf7\u5305\u62ec\u95e8\u724c\u53f7): &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-address\" \/><\/span><br \/>\n<b>\u533a\uff08Suburb\uff09<\/b> : &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-suburb\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-suburb\" \/><\/span><br \/>\n<b>\u90ae\u7f16\uff08Post Code\uff09 <\/b>: &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-post-code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-post-code\" \/><\/span><br \/>\n<b>\u624b\u673a\u53f7\u7801<\/b> : &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-mobile-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-mobile-phone\" \/><\/span><br \/>\n<b>\u5bb6\u5ead\u7535\u8bdd <\/b> : &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-home-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-home-phone\" \/><\/span><br \/>\n<b>\u7535\u5b50\u90ae\u7bb1 <\/b>: &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"patient-email\" \/><\/span>\n<\/p>\n<hr color=\"#7FFFD4\" style=\"height:10px\" \/>\n<p><b>\u6587\u5316\u80cc\u666f<\/b>\n<\/p>\n<p><b>\u51fa\u751f\u56fd\u5bb6<\/b> : &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-birth-country\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-birth-country\" \/><\/span>\n<\/p>\n<p><b>\u8bed\u8a00 <\/b> : &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-language-spoken\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-language-spoken\" \/><\/span>\n<\/p>\n<hr color=\"#7FFFD4\" style=\"height:10px\" \/>\n<p><b>\u76f4\u7cfb\u4eb2\u5c5e<\/b><br \/>\n<b>\u59d3\u540d <\/b> : &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-next-of-kin-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-next-of-kin-name\" \/><\/span><br \/>\n<b>\u5173\u7cfb <\/b> : &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-next-of-kin-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-next-of-kin-relationship\" \/><\/span><br \/>\n<b>\u624b\u673a <\/b> : &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-next-of-kin-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-next-of-kin-phone\" \/><\/span>\n<\/p>\n<hr color=\"#7FFFD4\" style=\"height:10px\" \/>\n<p><b>\u7d27\u6025\u8054\u7cfb\u4eba<\/b> (\u5982\u679c\u4e0e\u76f4\u7cfb\u4eb2\u5c5e\u4e0d\u540c)<br \/>\n<b>\u59d3\u540d <\/b> : &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-ec-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-ec-name\" \/><\/span><br \/>\n<b>\u5173\u7cfb<\/b> : &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-ec-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-ec-relationship\" \/><\/span><br \/>\n<b>\u624b\u673a<\/b> : &#160 <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-ec-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-ec-phone\" \/><\/span>\n<\/p>\n<hr color=\"#7FFFD4\" style=\"height:10px\" \/>\n<div class=\"content-column full_width\">\n\t<p><label>\u540c\u610f <\/label>\uff08\u7b7e\u7f72\u524d\u8bf7\u4ed4\u7ec6\u9605\u8bfb\u672c\u540c\u610f\u4e0e\u534f\u8bae\uff09\uff1a\n\t<\/p>\n<\/div>\n<div class=\"content-column full_width\">\n\t<p>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.<br \/>\n2)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.<br \/>\n3)I consent for AIM Health to send me reminders via SMS, phone call, letter or email.<br \/>\n4)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.<br \/>\n5)I agree that I need to make an appointment to discuss my results, or obtain referrals, prescription, medical certificate, MHCP, EPC, etc.<br \/>\n6)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.<br \/>\n7)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.<br \/>\n8)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 \u2013as per Medicare \/ insurance requirements under GP Management, etc.<br \/>\n9)I agree to the assignment of the Medicare benefit directly to the provider unless other arrangement on the day.\n\t<\/p>\n<\/div>\n<p><b>\u8bf7\u5728\u4e0b\u65b9\u7b7e\u540d<\/b>\n<\/p>\n<p><div class=\"wpcf7-form-control-signature-global-wrap\" data-field-id=\"patient-sign\">\n\t\t\t\t<div class=\"wpcf7-form-control-signature-wrap\" style=\"width:600px;height:200px;\">\n\t\t\t\t\t<div class=\"wpcf7-form-control-signature-body\">\n\t\t\t\t\t\t<canvas data-color=\"#1C2833\" data-background=\"#F2F3F4\" id=\"wpcf7_patient-sign_signature\" class=\"patient-sign\"><\/canvas>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"wpcf7-form-control-clear-wrap\">\n\t\t\t\t\t<input id=\"wpcf7_patient-sign_clear\" type=\"button\" value=\"Clear\"\/>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<span class=\"wpcf7-form-control-wrap wpcf7-form-control-signature-input-wrap patient-sign\">\n\t\t\t\t<input aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"hidden\" name=\"patient-sign\" id=\"wpcf7_input_patient-sign\"\/><input type=\"hidden\" name=\"patient-sign-attachment\" id=\"wpcf7_input_patient-sign_attachment\"\/><input type=\"hidden\" name=\"patient-sign-inline\" id=\"wpcf7_input_patient-sign_inline\"\/>\n\t\t\t<\/span>\n\t\t\t\n<\/p>\n<p>\u7b7e\u540d\u65e5\u671f <span class=\"wpcf7-form-control-wrap\" data-name=\"sign-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"2026-09-15\" type=\"date\" name=\"sign-date\" \/><\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner button\" id=\"form-submit\" type=\"submit\" value=\"\u53d1\u9001\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<input type=\"hidden\" name=\"trp-form-language\" value=\"zh\"\/><\/form>\n<\/div>\n<\/div>\n\n\n<p class=\"wp-block-paragraph\"><\/p>","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","footnotes":""},"class_list":["post-429","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/aimhealth.com.au\/zh\/wp-json\/wp\/v2\/pages\/429","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/aimhealth.com.au\/zh\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/aimhealth.com.au\/zh\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/aimhealth.com.au\/zh\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/aimhealth.com.au\/zh\/wp-json\/wp\/v2\/comments?post=429"}],"version-history":[{"count":4,"href":"https:\/\/aimhealth.com.au\/zh\/wp-json\/wp\/v2\/pages\/429\/revisions"}],"predecessor-version":[{"id":443,"href":"https:\/\/aimhealth.com.au\/zh\/wp-json\/wp\/v2\/pages\/429\/revisions\/443"}],"wp:attachment":[{"href":"https:\/\/aimhealth.com.au\/zh\/wp-json\/wp\/v2\/media?parent=429"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}