Appointment Form

Patient Appointment Form

It is essential that you complete the patient appointment form below, and agree to the cancellation policy before an appointment time slot can be arranged.

A consultation fee is chargeable for you to see Dr Tiong. This can be varied between $100 to $240 depending on the time spent with you during the consultation.
However, there are free consultations available with our Cosmetic Nurses or staffs who can offer you some basic information and generally speaking, their information is to direct you to a certain way in searching for an answer. They cannot provide technical details and information to your questions.
In order for you to secure a appointment, you must read and accept the terms of cancellation policy and tick yes in order to move forward for an appointment. An administration fee of $50 will be chargeable.
Name & Personal Details
First Name*
Last Name*
Date of Birth*
DD
MM
YYYY
Gender*
- Male
- Female
Number of Children*
If you have children, how old are they? (seperated by comma)
Occupation*
Marital Status*
Religious Affiliation*
Country of Birth*
Area of Concern for Consultation*
Please specify your area of concern for consulation:
Private Health Fund*
- Yes
- No
Please specify which fund:
Medicare
Medicare Number
Patient Number on Card
Expiry Date
Address Details
Address*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Phone Details
Home Phone*
Mobile Phone*
Work Phone
Preferred Method of Contact*
- Home Phone
- Mobile Phone
- Work Phone
- Do Not Contact Me by Phone / SMS
Email Details
Email*
Enter EmailConfirm Email
Emergency Contact
Contact Name*
Relationship*
Contact Number*

Misc Info
Where did you hear about us?*
- Friend
- Family
- Websites
- Magazines
- Newspaper
- Ads
- Others
If others, where?
Please let us know below if you have any other comments:
Confirmation
A consultation fee is chargeable for you to see Dr Tiong. This can be varied between $100 to $240 depending on the time spent with you during the consultation.
A free consultation is available with one of our Cosmetic Consultants. This is not personalised to your individual needs and is general in nature. For a tailored consultation to your individual requirements and needs you will need to see Dr Tiong for a formal consultation (fees apply).
In order for you to secure a appointment, you must read and accept the terms of cancellation policy and tick yes in order to move forward for an appointment. If a cancellation takes place in on the day of appointment $50.00 is chargeable .
Do you confirm that the details you have provided are true and accurate?*
- Yes, I confirm that the details I've provided are true and accurate.
Have you read, understood and AGREE to the terms and condition set forth by Dr. Tiong, including his cancellation policy?*
- Yes, I have read, understood and agreed to the terms and conditions set forth by Dr. Tiong, including the cancellation policy.

Patient Appointment Form

Step 1 of 4

Name & Personal Details

Medicare

Address Details

Phone Details

Email Details

Emergency Contact

Medical History

Medical History (Continued)

Misc Info

Confirmation