Patient information and consent form
1. PATIENT DETAILS
Title:
First Name:
Surname:
Other names:
Preferred names:
DOB:
Gender:
Pronouns:
Do you identify as Aboriginal or Torres Straight Islander?
Ethnicity:
Address:
Suburb:
Postcode:
Address:
Home Phone:
Mobile:
Work Phone:
Email Address:
Medicare No:
Ref No:
Expiry Date:
Health Care Card/ Pension Number:
Expiry Date:
Veteran Affairs Card Number:
Expiry Date:
2. NEXT OF KIN DETAILS
Title:
First Name:
Surname:
Address:
Suburb:
Post code:
Relationship:
Home Phone:
Mobile:
Work Phone:
3. EMERGENCY CONTACT DETAILS
Title:
First Name:
Surname:
Address:
Suburb:
Post code:
Relationship:
Home Phone:
Mobile:
Work Phone:
4. HOW DID YOU HEAR ABOUT US? (please circle):
Word of mouth/ Internet/ Yellow Pages/ Signage/ Live Locally/ Other:
5. ACCIDENT AND INJURY DETAILS
Is this visit for: Worker’s Compensation?
Motor Vehicle Injury or Accident?
Please be advised that until a claim number has been received you will be privatley charged for all Worker’s
Compensation or Motor Vehicle visits and will be required to pay on the day of the visit and claim the visits
back from your employer or the appropriate insurance department.
6. MEDICAL HISTORY
Allergies:
Blood Group:
Past Medical History:
Family Medical History (please include what family member and if they are maternal/paternal):
Current Medications:
Do You Smoke? (please circle):
Past Smoking History (Please circle): Light / Moderate / Heavy / Year stopped:
Do You Drink Alcohol? (please circle):
Past Drinking History (Please circle): Light / Moderate / Heavy / Year stopped
7. CONSENT
I understand that the above Medical Centre complies with the Privacy Act (1988) and as part of their Privacy Policy they are committed to protecting the privacy of individuals and their personal information. The purpose for collecting my personal information is to provide quality medical and health related services and associated account keeping, I understand that I have the right to request access to my Information except where access would be denied and that the above Medical Centre makes every effort to manage my information in accordance with the National Privacy Principles and keep my records accurate and up to date. I understand that I may withdraw my consent for the above Medical Centre to use and disclose my personal information (except when legal obligations must be met). My signature below Indicates that I have read the above and consent to: (cross out what is not relevant) The above Medical Centre collecting, using, storing and disposing of my personal information The release of relevant information to other health professionals to allow quality medical care (e .g. specialist, pathologist) Inclusion in a recall register to be advised of follow up visits, medical updates and health information The release of relevant personal information to my employer, their authorised representatives and their insurer in the case or a work related consultation or service. I understand that all accounts must be paid at the time of the consultation and that I will be responsible of payment of any children under the age of 16 years.
Name:
Signature:
Date: