Patient Form

Preferred Doctor

Title and Full Name*

Title First Name Middle Name Last Name

Address Details*

Address Suburb State Postcode

Postal Address (if different from street address):

Mobile Phone*

Work Phone

Home Phone

Email Address*

Date of Birth*

DD

MM

YYYY

Medicare Number

Ref #

Medicare Expiry Month

Medicare Expiry Year

Private Health Fund

Member #

DVA Number

DVA Card Colour

HCC/Pension Number

Expiry

Do you consent to SMS reminders?*

Yes
No

How did you hear about us?*

Referring Doctor*

First Name Last Name

Phone Number

Address

Usual GP (Other than above)

Name

First Name Last Name

Phone Number

Address

Workers Compensation/Third Party details (If applicable)

Is this a workcover related case?

Yes
No

Employer Name*

Employer Address Details*

Address Suburb State Postcode

Employer Number

Insurance Company Name*

Insurance Address Details*

Address Suburb State Postcode

Insurance Contact Name*

Insurance Contact Number

Date of Injury*

Claim Number*

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.

Print name and signature of Parent /Guardian (if under 18):

Signature of Patient (We will accept your typed name as an indication of consent)*

Patient Information & Consent Form

Workers Compensation/Third Party details (If applicable)

CONSENT TO COLLECT PATIENT INFORMATION

We take your privacy seriously. Please ask us for a copy of our privacy policy

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