Dr Vincent Loh

Brisbane-based specialist in Obstetrics, Gynaecology & Fertility care

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Patient Details Form

To save time on the day of your consultation, you can fill out your details below and click submit. Your details will be submitted electronically via email to our friendly receptionist.

To view the Privacy Consent Form, click here: Privacy Consent Form PDF

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Thank you for your response. ✨

Title(required)

Mrs.

Ms.

Miss.

Dr.

First Name(required)

Middle Name

Last Name(required)

Preferred Name

Maiden Name

Date of Birth(required)

Street Address(required)

Suburb(required)

Postcode(required)

Home Phone

Work Phone

Mobile Phone(required)

Occupation

Email(required)

Medicare No. (required)

Medicare Ref No. (required)

Medicare Exp. Date(required)

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(required)

Suburb of your usual GP/ Specialist(required)

Phone number of your usual GP/ Specialist(required)

Clinic of your usual GP/ Specialist

Name of your partner

Occupation of your partner

Name of Emergency Contact/ Next of Kin(required)

Phone number of Emergency Contact/ Next of Kin(required)

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