Medical Appointment Request Form

Medical Appointment Request Form

就诊预约表
Have you previously registered with Byte Health? 您是否已经在Byte Health注册过账号？
Patient's Name 就诊人姓名

First Name 名Last Name 姓
Email 邮箱
example@example.com
- Date of Birth 出生日期
  
  DayMonthYear
- Gender 性别
- Phone Number 手机号
  Format: 0000 000 000.
- Address 地址
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Medicare Number (If eligible) Medicare 号码 (如有)
- Medicare Reference Number (If eligible)
  Medicare Reference 号码
- IHI Number (If has) IHI号码 (如有)
- Emergency Contact 紧急联系人姓名
  
  First Name 名Last Name 姓
- Emergency Contact Number 紧急联系人电话
  Format: 0000 000 000.
- Emergency Contact Relationship 与紧急联系人的关系
- How did you hear about us? 您从哪里知道Byte Health？
- Would you like to schedule a doctor's appointment right now? 您现在需要预约看诊吗？
- Please select a service 请选择您需要的服务类型
- Height 身高 (CM 厘米)
- Weight 体重 (KG 千克)
- BMI Calculator BMI计算器
- Prior use of weight-loss medications? 此前是否使用过减重药物？
- Any personal or family history of thyroid cancer? 是否有家庭或个人甲状腺癌症病史？
- Any history of acute pancreatitis? 是否有急性胰腺炎病史？
- Past medical history (If any) 既往病史(如有)
- Current or previous long-term medications (If any) 其他慢性用药(如有)
- History of drug allergies (If any) 药物过敏史(如有)
- General Medical Consult 医疗咨询
- Please list your symptoms 请勾选您的症状：
- Please describe your symptoms 请描述相关症状：
- How many days do you need the certificate for? 您需要开具几天的假条？
- Start Date 开始日期
  
  DayMonthYear
  病假单仅支持开当日，最晚可开具至次日。
- End Date 结束日期
  
  DayMonthYear
  病假最长不支持超过3天
- Please briefly describe your symptoms 请简单描述您的症状：
- I confirm that my symptoms DO NOT require urgent medical attention, otherwise I would dial 000 immediately. 本人确认目前的症状不需要任何紧急救助，一旦出现相关紧急情况，将立即拨打000急救热线。
- I agree that if my symptoms do not improve, I will consult a GP as soon as possible. 本人同意，如果症状没有改善，将尽快咨询GP。
- Are you currently taking this medication? 您目前已经在使用上述药物吗？
- How many medications are you requesting? 您需要几种药物？
- Medication(s) Needed 请列出您需要的全部药品：
- Other Information for the Doctor (Optional) 其他您想告诉医生的情况 (可选）
- How would you like to receive and review your test results? 您希望如何获取并查看您的检查报告？
- Which categories of medical tests are you requesting? 您需要开具哪些检查？
- Please specify the type of radiology referral you require and briefly describe your symptoms. 请说明您需要的影像检查，并简单描述您的症状：
- Please specify your requested medical specialty and describe your symptoms. 请填写您要就诊的专科，并描述相关症状：
- Appointment
  
  请选择您期望的沟通日期和时间段
- Appointment Date 期望沟通时间
  
  DayMonthYear
- Preferred Time Slot 时间段
- 如您有特殊时间需求，请在下方注明，我们会尽量协调。
  If you have specific time preferences, please indicate them below, and we will do our best to accommodate.
- Payment
  
  请选择您的支付方式及对应的支付币种，并将付款完成页面截图，发送给微信客服。转账时，请备注真实姓名。
- Byte Health 为自费制远程医疗服务，本服务不适用于 Medicare 或私人医保报销，所有费用均为自费支付。
  
  Byte Health is a private, self-funded telehealth service. Our consultations are not covered by Medicare or private health insurance and are fully out-of-pocket.
  
  如对服务不满意请于电话咨询时向医生明确提出退款申请，咨询服务后的退款申请将不予处理。
- Total Amount (AUD) 预估费用总计（澳元）
- Total Amount (CNY) 预估费用总计（人民币）
- Bank Transfer Recipient Information 澳元银行转账信息
  Account name: BYTE HEALTH PL
  BSB 013160
  Account number: 176966095
Should be Empty:

Medical Appointment Request Form

Appointment

Payment