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Helping you with
every breath
Breathe Freely,
Enjoy life
Value lung health,
we do!
A breath of fresh air
is all you need
Lung Health is our
Expertise
Lung Health is our
Expertise
Always striving for quality
care and outcomes
The Lungh Health Clinic’s New Patient Form
your contact details and identification
Title
*
Mr.
Mrs.
Ms.
Dr.
Miss
Prof.
Surname
*
First Name
*
(as per Medicare Card)
Middle Name
Known As
(as different from above)
Date of Birth
*
Address
*
Suburb
*
Postcode
*
State
*
Country
*
---
Country 1
Country 2
Country 3
Mobile Phone No.
*
Home Phone No.
*
Work Phone No.
Home Fax No.
Email
*
Public Hospital
Medical Number
(if known)
Would you like to make an appointment reminders sent by SMS to your mobile phone?
*
Yes
No
Do you wear a hearing aid?
*
(Please wear for your visit to us)
Yes
No
MEDICARE & PRIVATE INSURANCE DETAILS
Medicare Number
*
The number in front of your name
*
Are you registered with Medicare for electronic payment of your accounts
*
Yes
No
Private Health Fund
HBF
Medibank Private
BUPA
Other
Private Health
Fund Number
Aged Person / Senior
Health Care Card Number
Veteran's Affairs Number
Veteran's Affairs
Card Color
*
Email
*
Public Hospital
Medical Number
(if known)
EMERGENCY CONTACT DETAILS
Name
*
Relationship
*
Address
*
Home Phone Number
*
Mobile Phone Number
*
USUAL GENERAL PRACTITIONER
Dr's Name
*
Dr's Clinic Name
& Address
*
Dr's Email Address
(if known)
*
Required Field
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