Dr Chien-Wen Liew NEW PATIENT FORM "*" indicates required fields Title Mr Mrs Ms Miss Master Dr First Name Middle Name Last Name Preferred Name Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Occupation HiddenContact DetailsMobile Phone Number*We will send important SMS's to you - this will be the preferred number for us to contact you too. Home Phone NumberEmail Enter Email Confirm Email We will send important emails to this email address. Please ensure it is accurately typed inAddress Street Address Suburb State / Province / Region ZIP / Postal Code Please do not input a PO BOX hereNext of KinHere we will ask a few details about your Next of Kin - someone that we will contact if we can't get a hold of you or if we need to notify someone in your absence. Full Name Next of Kin's namePhoneNOK best contact numberRelationshipSELECT AN OPTIONParentSonDaughterSpousePartnerSiblingRelativeFriendOtherWhat is the relationship of your NOKHiddenReferring DoctorName of Referring Doctor* Referring Doctor's Clinic* Is this your usual GP* Yes No - My usual GP is different I don't have a regular GP Usual General Practitioner Who is your usual GP if it is not the referring GP. We will send correspondence to this doctor too. Usual General Practitioner's Clinic Physiotherapist Name and Clinic (If you have a regular one)Chiropractor Name and Clinic (If you have a regular one)HiddenHealthcare DetailsMedicare Number The full Medicare number - not including the reference number - we will ask that on the next question. Medicare Reference (Reference number is the number next to your name on the card) Expiry MonthSELECT MONTH010203040506070809101112The expiry MONTH of your Medicare careExpiry YearSELECT YEAR20242025202620272028202920302031Now the year - when does your Medicare card expire?HiddenPrivate Health DetailsFund NameSELECT FUNDACA Health Benefits FundAHM Health InsuranceAustralian Unity health LimitedBUPA AustraliaCBHS Health FundCDH Benefits FundCUA Health LimitedDefence Health LimitedDoctors Health FundGMF HealthGMHBA LimitedGrand United Corporate healthHBF HealthHCFHealth Care Insurance LimitedHealth Insurance Fund of AusytaliaHealth partnersLatrobe HealthMedibank PrivateMildura Health FundNavy HealthNIB Health FundPeoplecare Health FundPolice HealthQueensland Country Health FundRailway & Transport Health FundReserver Bank health SocietySt. Lukes HealthTeachers Health FundTransport HealthTUHWestfund limitedWe're going to ask questions about your Private health fund now. What is your Fund name?Fund Number What is your member number for your fund?Do you have a concession card Yes No Type of Concession Card Aged Pension Disability Healthcare Card DVA Card Carers Pension Aged Pension Card Number Expiry MonthSELECT MONTH010203040506070809101112Aged pension card expiry monthExpiry YearSELECT YEAR20172018201920202021202220232024202520262027When does your aged care card expire - year?Disability Card Number Expiry MonthSELECT MONTH010203040506070809101112Expiry YearSELECT YEAR20172018201920202021202220232024202520262027Healthcare Card Number Expiry MonthSELECT MONTH010203040506070809101112Expiry YearSELECT YEAR20172018201920202021202220232024202520262027DVA Card TypeGOLDWHITEORANGEDVA Number Carers Number HiddenMedical QuestionnaireMedical Conditions Diabetes Rheumatoid Arthritis Smoker Previous Blood Clots in legs or lungs Hep B, Hep C, HIV Blood Thinners (i.e. Aspirin, Warfarin, Plavix) What medical conditions do you have from the list below?I am seeing Dr Liew for my* Hip Knee Select the main issues todayHow did you hear about usGP ReferredFriend or Family memberSocial MediaMessenger / PaperSearch EngineSeminar/EventOtherThe consultation and surgical fees charged by Dr Liew are as follows: Initial Consult: $280 (Aged Pension $180). Review of Consult: $130 (Aged Pension $100). A proportion is returned from medicare of these fees. Surgery fees are a set fee, with a rebate from Medicare/Healthfund. Please check with your health fund that the following item numbers are covered (49318 for hips and 49518 for knees). Approximate fees are $6280 for a hip replacement or knee replacement (prior to any rebates from Medicare/Healthfund - usually approx $1400 rebate from medicare+health fund). ACCOUNTS ARE PAYABLE IN FULL ON THE DAY OF CONSULTATION and 5 days before SURGERY It is a term of the provision of these services that the patient shall be liable for all debt collection fees and charges, including but not limited to agent fees, solicitor costs and disbursements in the event that the collection is required. Please note that Medicare does not completely cover the cost of your consultation or surgery. Other fees may be incurred for medical forms for insurance, income protection and other such forms. Dr Liew does not undertake Workcover or 3rd party work. Dr Liew does not do 2nd opinion work. I understand that payment of the account is my full responsibility. I consent to the release and communication of information from and to any other medical provider, for the purpose of my ongoing clinical management and for ongoing clinical research, audit and education (letters, Images, and Video). Clinical images may be used in a de-identified manner for marketing or education purposes. I agree with the Terms and Conditions Yes No If you need to, please go back to re-read the terms and conditions, before agreeing. You will sign the form on the next screen which is the end!InitialPlease sign/initial this to advise that you wish to be a patient of Dr Chien-Wen Liew and have read the information within this form. We will send another email to you tomorrow with some information about Dr Liew's practice.