{"id":429,"date":"2022-01-12T11:24:56","date_gmt":"2022-01-12T11:24:56","guid":{"rendered":"https:\/\/aimhealthmelbourne.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:\/\/aimhealthmelbourne.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<div class=\"uacf7-form-428\"><!-- Medicare section -->\n<hr color=\"#7FFFD4\" style=\"height:10px\" >\n<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> \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\n<!-- Concession card -->\n<hr color=\"#7FFFD4\" style=\"height:10px\" >\n<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>  \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\n\n<hr color=\"#7FFFD4\" style=\"height:10px\" >\n<b><mark>\u5982\u679c\u60a8\u6ca1\u6709\u533b\u4fdd\u5361<\/mark><\/b>\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> \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>\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\n<hr color=\"#7FFFD4\" style=\"height:10px\" >\n<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>\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<div class=\"content-column full_width\"><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> <\/div> <div class=\"clear_column\"><\/div>\n\n<hr color=\"#7FFFD4\" style=\"height:10px\" >\n<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> \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> \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>\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> \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> \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\n<hr color=\"#7FFFD4\" style=\"height:10px\" >\n<b>\u6587\u5316\u80cc\u666f<\/b>\n\n\n<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\n<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\n\n<hr color=\"#7FFFD4\" style=\"height:10px\">\n<b>\u76f4\u7cfb\u4eb2\u5c5e<\/b> \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> \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> \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\n<hr color=\"#7FFFD4\" style=\"height:10px\">\n<b>\u7d27\u6025\u8054\u7cfb\u4eba<\/b> (\u5982\u679c\u4e0e\u76f4\u7cfb\u4eb2\u5c5e\u4e0d\u540c) \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> \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> \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\n<hr color=\"#7FFFD4\" style=\"height:10px\" >\n<div class=\"content-column full_width\"><label>\u540c\u610f <\/label>\uff08\u7b7e\u7f72\u524d\u8bf7\u4ed4\u7ec6\u9605\u8bfb\u672c\u540c\u610f\u4e0e\u534f\u8bae\uff09\uff1a <\/div>\n<div class=\"content-column full_width\"><br><\/br>\n1)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.\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. \n3)I consent for AIM Health to send me reminders via SMS, phone call, letter or email.\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. \n5)I agree that I need to make an appointment to discuss my results, or obtain referrals, prescription, medical certificate, MHCP, EPC, etc.\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.\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.\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.\n9)I agree to the assignment of the Medicare benefit directly to the provider unless other arrangement on the day.\n\n<\/div>\n\n \n<b>\u8bf7\u5728\u4e0b\u65b9\u7b7e\u540d<\/b>\n\n<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\n \n\n\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=\"2026-09-18\" type=\"date\" name=\"sign-date\" \/><\/span>\n\n\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner button\" id=\"form-submit\" type=\"submit\" value=\"\u53d1\u9001\" \/><\/div><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:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/pages\/429","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/comments?post=429"}],"version-history":[{"count":4,"href":"https:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/pages\/429\/revisions"}],"predecessor-version":[{"id":443,"href":"https:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/pages\/429\/revisions\/443"}],"wp:attachment":[{"href":"https:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/media?parent=429"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}