HPV Vaccination Registration Form (New Patient) / HPV疫苗接种新患者登记表

Patient Information / 患者信息
Full Name (in English) / 姓名（英文）

First Name / 名Last Name / 姓
Date of Birth / 出生日期

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Phone Number / 电话号码
For overseas numbers, please omit the leading 0. / 如为海外号码，请去掉开头的0。Format: 0000-000-000.
Email Address / 电子邮箱
Address / 地址

Street Address

Street Address Line 2

Suburb / City / 城区、城市State / Province / 州、省

Postal / Zip CodeCountry
Gender / 性别
Nationality / 国籍
Emergency Contact / 紧急联系人

※ An overseas contact is fine. / ※ 海外联系人也可以。
Name (in English) / 姓名（英文）

First Name / 名Last Name / 姓
Phone Number / 电话号码
For overseas numbers, please omit the leading 0. / 如为海外号码，请去掉开头的0。Format: 0000-000-000.
Relationship to You / 与您的关系
Health Insurance / 保险信息
Type of Insurance / 保险类型
If you selected "Other", please enter the name of your insurance company. / 如选择“其他”，请填写保险公司名称。（英文）
Please attach your insurance certificate or membership details (photos are OK). / 请上传保险单或会员号等信息（可上传照片）。

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About Your Health / 健康状况
Drug Allergies / 药物过敏
If you selected "Yes", please provide details. / 如选择“有”，请填写详情。（英文）
Other Allergies / 其他过敏
If you selected "Yes", please provide details. / 如选择“有”，请填写详情。（英文）
Medical History / 病史
If you selected "Yes", please provide details. / 如选择“有”，请填写详情。（英文）
Current Medications / 目前正在服用的药物
If you selected "Yes", please provide details. / 如选择“有”，请填写详情。（英文）
Smoking / 吸烟
If "Yes", average number of cigarettes per day / 如选择“有”，请填写每天平均吸烟支数
Alcohol / 饮酒
If "Yes", average number of drinks per week / 如选择“有”，请填写每周平均饮酒杯数
Family Medical History (if none, please write "None") / 家族病史（如无，请填写“无”）（英文）
Please sign below to confirm that you agree to our Privacy Policy. / 请在同意隐私政策后签名。
How did you hear about our clinic? / 您是如何得知本诊所的？

School / Agent / Insurance company, etc. (please tell us the name) / 学校、中介、保险公司等（请告知名称）
HPV Vaccination / HPV疫苗接种
Have you ever received an HPV vaccine in any country? / 您是否曾在任何国家接种过HPV疫苗？
Please tell us your visa type for your stay in Australia. / 请告知您在澳洲的签证类型。

Other (please specify) / 其他（请填写）
Type a question
Please note that we are unable to accept vaccination bookings on weekends or public holidays.
Should be Empty:

Patient Information / 患者信息

Emergency Contact / 紧急联系人

Health Insurance / 保险信息

About Your Health / 健康状况

HPV Vaccination / HPV疫苗接种