Patient Information & Privacy Consent

Name*

Prefix First Last

Date of Birth*

DD

MM

YYYY

Preferred Name (if different):

Residential Address*

Street Address Address Line 2 City State Postcode

Do you have a different Postal Address?*

Yes
No

Postal Address (if different):

Street Address Address Line 2 City State / Province / Region Postcode

Mobile Phone*

Do you consent to receiving messages/appointment reminders by SMS?

Yes
No

Home Phone

Work Phone

Email*

Medicare Number*

Medicare Ref number (number beside your name)*

Do you have Private Health Cover?*

Yes - Gold
Yes - Silver
Yes - Bronze
No

Private Health Fund

Private Health Member Number

Please select your cover:

Hospital
Extras

Dept. Veteran Affairs number (if applicable)

DVA Card Colour

Next of Kin*

Next of Kin Relationship:*

Next of Kin Phone*

Usual GP:*

GP Suburb:*

Other interested GP/Specialist (please advise name and clinic location)

Is this a Workcover claim, if so claim number:

Name of Insurer

Name of Employer

Account Details

Is the person listed above responsible for payment of the account?*

Yes
No

Please provide the details of the person responsible for payment of the account (only if different from patient details)

Name of person responsible for account

First Last

Phone no. of person responsible for account

Address of person responsible for account

Street Address Address Line 2 City State / Province / Region Postcode

Consent to Collect Patient Information*

I have read and understood the below 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 (which may include photos) so that we may properly assess, diagnose and treat your health care needs. We will use the information you provide in the following ways:

Administrative purposes in running the 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.

I have read the information above and 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 healthcare 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 be legitimately withheld. I understand I will be given an explanation in these circumstances.

I consent to the handling of my information by this practice for the purposes set out above, subject to any limitation on access or disclosure of which I have notified this practice.

Confidential patient information might be used for research and medical papers written by this practice. This unidentified data will always remain confidential however will be published in journals and presented at national and international meetings.

I accept responsibility for payment of all my accounts.

Helping you achieve a healthier lifestyle.

Patient Information & Privacy Consent

Account Details

Dr Ian Martin Surgery

Scheduling an appointment is an important first step towards a sustainable, healthier and brighter future.