Your Email

Your Address & Postcode

Medicare Reference
12345678910

Department Of Veteran's Affairs

Next Of Kin

Their Relationship To You

Next Of Kin Contact Details

Local Doctor's Name

Local Doctor's Address

Local Doctor's Phone

Do You Have Any Of The Following?
Heart ProblemsDiabetesBleeding TendencyHigh Blood PressureTBAsthmaHay FeverEczemaPsoriasisSkin Cancer

Are you allergic to any medications YesNo

If yes, which ones?

Do you take blood thinning medications (such as aspirin)?
YesNo

What medications do you currently take? (If not on Referral)

What past medical problems or operations have you had? (If not on Referral)

Have any family members been diagnosed as having:
EczemaPsoriasisSkin CancerSkin Disease

PLEASE NOTE: In accordance with standard practice, accounts are to be settled on the day of consultation. Methods of payment availbale include Cheque, Eftpos, Visa, Mastercard, Bankcard or Cash. With a valid referral, most consultations and procedures are eligible for a Medicare Rebate. Thank you
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PATIENT INFORMATION CONSENT FORM

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 healthcare, 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 assessed for these purposes, and we will note this on your record accordingly.
• Disclosure of data (that does not identify you) 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: The practice fees are above the Schedule Fee (except Veterans Affairs patients). If the fees are likely to cause you financial hardship, please discuss this with the treating doctor or our practice staff.
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ACKNOWLEDGEMENT OF CONSENT

• I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling the patient information.
• 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 by this request.
• I understand that if my information is to be used for any 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, I have advised to the practice, on access or disclosure.

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