A breath of fresh air
is all you need
Value lung health,
we do!
Always striving for quality
care and outcomes
Lung Health is our
Expertise
Lung Health is our
Expertise
Helping you with
every breath
Breathe Freely,
Enjoy life

New Patient Form

Please complete this form in its entirety, and tick the boxes to show that you have read and consented to the provision of your personal information and the fee agreement.  This information is essential for making your appointment.

* Please note that all information transmitted from our patients to our clinic via the website is encrypted and a dedicated email address is used to receive electronic communications.

The form can be either completed online and sent electronically, or downloaded and printed out for manual completion and return by email, post or fax to The Lung Health Clinic.

To download this form for manual completion, please click here. 

This is a private practice | payment of accounts is required on the day of the consultation
 
Please ensure your bank account details are lodged with Medicare as they now require these details as of July 2016.
Fields marked with an * are required
YOUR CONTACT DETAILS AND IDENTIFICATION
MEDICARE & PRIVATE INSURANCE DETAILS
EMERGENCY CONTACT DETAILS
USUAL GENERAL PRACTITIONER
PERSONAL AIDS AND DEVICES
IMPORTANT MEDICAL INFORMATION

Please tick the relevant boxes if any of the problems listed are related to why you are coming to see us

MEDICATION HISTORY

DRUG ALLERGIES

Name of Drug

Type of Reaction

SMOKING HISTORY
OCCUPATION HISTORY