PHONE (02) 8076 5400
Dr Charlie Lin
Dr Edmund O’Leary
Joint Replacement Surgery
Total Hip Replacement
Total Knee Replacement
MAKO Partial Knee Replacements (MAKO UKR)
Patient Information & Consent Form
Title and Full Name
Postal Address (if different from street address):
Date of Birth
Private Health Fund
DVA Card Colour
Do you consent to SMS reminders?
How did you hear about us?
Usual GP (Other than above)
Workers Compensation/Third Party details (If applicable)
CONSENT TO COLLECT PATIENT INFORMATION
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 medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. 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 as advised by you.
I understand the reasons why my information must be collected.
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 am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.
I understand that if my information is to be used for any purpose other than the above, my consent will be sought.
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 of which I may notify this practice.
Signature of Patient (We will accept your typed name as an indication of consent)
Print name and signature of Parent /Guardian (if under 18):
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