NEW PATIENT FORM

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 through 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.

By consenting, I have:

Read the information above and understood the reasons why my information must be collected.
Accepted to the collection, use, and disclosure of my personal and health information in accordance with the Privacy Act 1988 and the clinic's Privacy Policy for the purpose of providing specialist medical services, billing, and related administration.
Understood that:
- Specialist services may involve out-of-pocket costs not fully covered by Medicare or other funders.
- A valid referral is required to claim a Medicare rebate.
- Fees may apply for reports, procedures, cancellations, or non-attendance.
Understood 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.
Been made 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.
Understood that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.
Allowed for 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.
Allowed for receiving SMS appointment reminders from the clinic.
Allowed for receiving emails from the clinic.
Declared the information provided above is true and correct to the best of my knowledge.

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.

NEW PATIENT REGISTRATION FORM