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New Patient Registration - Child

Title

Parent / Carer

(Complete at least one section for account holder information)

Billing

If you do not have medicare, please leave the field as all nines

Referral

Click or drag files to this area to upload. You can upload up to 2 files.
If you have a scan or photo of your referral, please feel free to upload it here. Please include all pages, including the referring doctor provider number
Click or drag files to this area to upload. You can upload up to 4 files.
Feel free to also upload and relevant medical reports and investigations that you would like to share with our doctor for your upcoming appointment
If different from above
If different from above
If different from above

EMERGENCY CONTACT

Please tick if you consent for us to share your medical information with the provided emergency contact

Patient Consent

CONSENT TO COLLECT PATIENT INFORMATION

PRIVACY ACT 1988 • PRIVACY ACT AMENDMENTS-PRIVATE SECTOR-ACT 2000

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:

  1. Administrative purposes in running our medical practice.
  2. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
  3. Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals.
  • I have read the information above and understand the reasons why my information must be collected.
  • I am aware that this practice has a privacy policy on handling patient information.
  • 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 I request access to information about me, the practice will be entitled to charge me fees to cover:
    • time spent by administrative staff to provide access (at the employee’s hourly rate of pay)
    • time spent by a medical practitioner to provide access (at the practitioner’s ordinary sessional rate)
    • photocopying and other disbursements at cost

• 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 the practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.

Financial Consent

I understand that payment for services is due at time of consultation.