First Name*

Surname*

Date of Birth*

Address*

Post Code*

Mobile*

Email*

Medicare Number*

Ref No (number in front of name on Medicare card)*

Health Fund*

Membership No*

Emergency Contact

Partner’s Name

Mobile

Or

Nominated Family Contact

Mobile

Relationship

GP Details

GP’s Name

GP’s Address

Patient Privacy Act

We are committed to protecting the privacy of patient information and to handling personal information in a responsible manner in accordance with Privacy Act 1988 (Cth), the Privacy Amendment (Enhancing Privacy Protection) Act 2012, the Australian Privacy principles and relevant State and Territory privacy legislation.

As such, we ask that you read this sheet regarding the collection, use and disclosure of your personal and medial information and then sign to say you have read and agree with the statement.

We collect information that is necessary and relevant to provide you with medical care and treatment, as well as manage our medical practice. Your files may contain the following information:
– Personal details (name, address, date of birth, Medicare number and health details)
– Your medical history
– Note made during the course of your medical consultation
– Referrals to other Health Services Providers
– Results and reports received from other Health Services Providers

This information is provided by you or arises as a consequence of information provided by you. It may be necessary for us to obtain/send copies of reports such as x-rays, ultrasounds, pathology and correspondence from our practice to obtain these records. Please note, medical records cannot be released with your consent in writing except when they are required by law such as a subpoena.

I have read the Patient Privacy Act.
Yes

I give my permission for these details to be used in communication with other Health Professionals involved in my care.
Yes

Patient signature*

Date*

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