Simply fill out the online form below OR click on the blue button to access a hardcopy version.
Your First Name
Your Address & Postcode
Your Date Of Birth
Do you wish to receive SMS reminders YesNo
Medicare Reference 12345678910
Private Health Insurer
Private Health Number
Does Your Health Insurance Cover You For HospitalExtrasBoth
Pension Card Number
Pension Card CRN
Department Of Veteran's Affairs
Please Tick WhiteGold
Next Of Kin
Their Relationship To You
Next Of Kin Contact Details
Local Doctor's Name
Local Doctor's Address
Local Doctor's Phone
Medical History - Have You Had Any Serious Illness Or Surgery? Please Briefly Outline...
Do You Have Any Of The Following? High Blood PressureHeart ProblemsPacemakerDiabetesKidney ProblemsAllergies
Please List Any Medications
We require your consent to collect personal information about you. Please read this information carefully and mark the relevant fields below.
This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways:
Administrative purposes in running our medical practice. Billing purposes, including compliance with Medicare and Health insurance Commission requirements.
Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals.
Disclosure to other doctors in the practice, locums and by Registrars attached to the practice for the purpose of patient care and teaching. Please let us know if you do not want your records accessed for these purposes, and we will note your record accordingly.
Disclosure for research and quality assurance activities to improve individual and community health care and practice management. You will be informed when such activities are being conducted and given the opportunity to “opt out” of any involvement.
Fees: My practice fees are above the Schedule Fee (except Veterans’ Affairs patients), but below the AMA rate. If my fees are likely to cause you financial hardship, please discuss this with me or my secretary. __________________________________________________________________
I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me.
I understand that I may request access to my health records. This must be in writing and I must provide proof of my identity prior to the request being authorised. Charges may be incurred with this request. Your request will be handled within 45 days of the letter of request being received and/or within 7 days of your payment being received.
I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained. I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I notify this practice of.
I have read, understand and give my consent for the information above YesNo
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