Patient Details Form

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Title(required)

Mrs.

Ms.

Miss.

Dr.

First Name

Middle Name

Last Name

Preferred Name

Maiden Name

Date of Birth

Street Address

Suburb

Postcode

Home Phone

Work Phone

Mobile Phone

Occupation

Medicare No.

Medicare Ref No.

Medicare Exp. Date

Health Fund

Health Fund Membership Number

Have you been with your health fund a minimum of 12 months as there are waiting periods for Obstetric care? If not, please ensure to discuss the fees with our reception staff(required)

Yes

Name of your usual GP/ Specialist

Suburb of your usual GP/ Specialist

Phone number of your usual GP/ Specialist

Clinic of your usual GP/ Specialist

Name of your partner

Occupation of your partner

Name of Emergency Contact/ Next of Kin

Phone number of Emergency Contact/ Next of Kin

Do you authorise Dr. Loh's practice to send SMS reminders to your mobile phone number? (required)

Yes

Are you the person responsible for your account? (Payment required on day of consultation - EFTPOS facilities are available, however, we do not accept American Express or Diners Card). (required)

Yes

If Other,

Dr Vincent Loh

Brisbane-based specialist in Obstetrics, Gynaecology & Fertility care

Patient Details Form

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