VECA Medical Health Centre Enrolment Form 家僑醫療健康中心家庭醫生注册表

Parent or Caregiver to sign if you are under 16 years（如果您未满16岁，需父母或监护人签字）

I intend to use this practice as my regular and on-going provider of general practice / GP / health care services.我选择此家庭医生诊所作为我的医疗提供者/家庭医生/基本卫生保健服务I understand that by enrolling with this practice, I will be included in the enrolled population with the Primary Health Organisation (PHO) this practice belongs to, and my name address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers.我明白在此诊所注册的同时我也将在诊所归属的基本卫生保健服务机构注册，我的名字，地址及其它身份证明将被保留在此诊所和此机构。I understand that if I visit another health care provider where I am not enrolled I may be charged a higher fee.我明白如果我去除此诊所以外的其它诊所，我可能会被要求支付更高的诊费。I have been given information about the benefits and implications of enrolment and the services this practice and PHO provides along with the PHO's name and contact details. I have read and I agree with the Use of Information Statement. The information I have provided on the Enrolment Form will be used to determine eligibility to receive publicly-funded services. Information may be compared with other government agencies, but only when permitted under the Privacy Act.我已经得到关于此基本卫生保健服务机构注册的健康信息隐私权声明信息。I agree to inform the practice of any changes in my contact details and entitlement and/or eligibility to be enrolled.我同意如果我的资格证明有任何变动我会通知诊所。