Queensland Rehabilitation Specialists
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Patient Details
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Indicates required field
First Name
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Surname
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D.O.B
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Please enter as DD/MM/YYYY
Address
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Line 1
Line 2
City
State
Zip Code
Country
Home Phone Number
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Mobile Number
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Email
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Occcupation
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Medicare Number
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Medicare Reference Number
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DVA Card Number
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DVA Card Type
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Orange, White or Gold
Private Health Insurance Fund Name:
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Private Health Fund Membership #:
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Private Health Fund Reference Number:
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Emergency Contact and Next of Kin Details
Emergency Contact:
First Name
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Surname
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Relationship to you
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Parent, Sibling, friend
Contact Number
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Next of Kin:
First Name
*
Surname
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Relationship to you
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Contact Number
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Cultural background
Knowing your cultural background can help us provide healthcare that meets your individual needs.
Are you of Aboriginal or Torres Strait Islander origin?
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No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander
Other cultural background (Mediterranean, Asian, African)
*
Country of birth
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Allergies and Medicines
List allergies and intolerances to medications
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Describe your reactions if any:
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List regular medications and doses, and complementary medicines and doses
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Consent
As a patient of our medical practice 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. We aim to protect the privacy and secure storage of your health information. You can request a copy of our privacy policy, which includes information about the collection, use, and disclosure of your health information.
We require your consent to collect personal information about you and to 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 though referral to other doctors, or for medical tests and in the reports or results returned to us following referrals.
Disclosure to other doctors in the practice, locums etc. attached to the practice for the purpose of patient care and teaching.
For research and quality assurance activities to improve individual and community health care and practice management. Usually information that does not identify you is used but, should information that will identify you be required, you will be informed and given the opportunity to “opt out” of any involvement.
To comply with any legislative or regulatory requirements e.g.,notifiable diseases.
For reminder letters which may be sent to you regarding your health care and management.
Please read this consent form carefully, and sign where indicated below. You can decline to have your health information used in all or some of the ways outlined above but it may influence our ability to manage your health care to provide the best outcome for you.
I have read the information above and understand the reasons why my information must be collected.
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Yes
No
I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the quality of health care and treatment given to me.
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Yes
No
I am aware of my rights to access the information collected about me, except in some circumstances where access may be legitimately withheld. I will be given an explanation in these circumstances
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Yes
No
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.
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Yes
No
I consent to the handling of my information by the practice for the purpose set out above, subject to any limitations on access or disclosure of which I notify this practice.
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Yes
No
Consent to receive SMS appointment reminders from the clinic:
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Yes
No
Consent to receive emails from the clinic:
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Yes
No
Submit
Home
Providers
For Patients
Patient Information
Getting Here & Parking
Fees
Cancellation Policy
QLD Locations
Contact Form
New Patient Form
Referral Form
New Fighters
Medicolegal Assessments