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Dr Patrick Lim
Orthopaedic Spine Surgeon
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New Patient Registration Form
PATIENT DETAILS
Salutation
(Required)
Mr
Mrs
Dr
Miss
Ms
First name
(Required)
Last name
(Required)
Preferred Name
Date of Birth
(Required)
Day
Month
Year
Gender
Male
Female
PATIENT CONTACT DETAILS
Mobile Number
(Required)
Email
(Required)
Multi-line address
Country/Region
(Required)
Address
(Required)
City
(Required)
Zip / Postal code
(Required)
REFERRAL DOCTOR
Referring Doctor’s Name
(Required)
Address
Family Doctor/ Regular General Practitioner Name (if different to referring doctor)
Address
Upload Referral
(Required)
Upload File
PREVIOUS IMAGING
Type
Where
MEDICARE
(Please use Parent/Guardian details if patient is less than 14 years old)
Name as it appears on Medicare Card
Medicare Card No.
Ref
Expiry
Parent/Guardian DOB (ONLY if patient is 14 years old or under)
PRIVATE HEALTH INSURANCE
Do you have private health insurance?
(Required)
Yes
No
WORKCOVER/ CTP CLAIM
Is this a Workcover or CTP Claim?
(Required)
Yes
No
PENSION / HCC/DVA CARD
Do you have an aged pension card, healthcare card or a DVA card?
(Required)
Yes
No
RELEVANT DOCUMENTS
Please upload any relevant documentation such as reports etc
Upload File
SIGNATURE
I confirm that above information I have provided is true, complete and accurate.
(Required)
Yes
Signature
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Today's Date
(Required)
Day
Month
Year
Time
:
Hours
Minutes
AM
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