New Participant

Welcome! This takes a few minutes. Fields marked * are required.

Your Privacy

WellTogether101 Foundation collects your details to provide GP care, obtain Medicare benefits with your consent, and measure program outcomes in de-identified form. Your information is stored securely, access is restricted to Dr Jenny Yuan and authorised staff, and it is never sent by email. You can ask to see or correct your information at any time via info@welltogether101.com.

About You

Full Name (exactly as on your Medicare card) *

Date of Birth *

Home Address *

How to Reach You

Mobile Phone *

Email Address

WhatsApp Number (if different from your mobile)

Preferred Language

Would you like an interpreter at sessions? *

Emergency Contact

Emergency Contact Name *

Emergency Contact Phone *

Medicare Card

Medicare Card Number

Individual Reference Number (IRN)

Card Expiry

Your Consent

I consent to receiving GP health services from Dr Jenny Yuan as part of WellTogether101 support groups and stress-management programs. I request that my Medicare benefit for these services be paid directly to Dr Jenny Yuan (bulk billing). This authority is ongoing and remains in force until I revoke it in writing. I understand my details are used for my care, Medicare billing, and de-identified program outcome reporting.

I have read and accept this consent.

Signature — please type your full name *