Patient Information Privacy Form

General Details
Title*
Last Name*
First Name*
Date of Birth*
MM slash DD slash YYYY
Address*
Home Phone
Work Phone
Mobile Phone*
Email Address*
Next of Kin/Emergency Contact*
Relationship*
Home Phone
Mobile Phone*
If we are able to contact you, would you like us to leave a message with whoeven answers the phone?*
- Yes
- No
Are you happy for us to confirm your appointments via SMS/text message?*
- Yes
- No
Financial Details
Medicare Number*
Expiry Date*
MM slash DD slash YYYY
Reference Number*

On the left side of name
Private Health Insurance*
- Yes
- No
Fund Name*
Membership Number*
Veterans Affairs Number
Expiry Date
MM slash DD slash YYYY
Pension Number
Expiry Date
MM slash DD slash YYYY
Type
Other Type*
Referral Details
Referring Doctor*
Phone*
Address*
Family Doctor
Phone
Address
Important Information
Pathology and Radiology Fees: Doctors are not responsible to pay the fees in relation to pathology and radiology ordered on your behalf.

Payment of Fees: Payment of fees at the time of consultation is required. Collection fees will be charged and payable on any outstanding debts.

Privacy Policy: Our staff will not disclose this information to any third party. Your information is stored on a secure password protected information system. Onward referral to another specialist will require the duplication of this form, your record and test results. If results are not received by the practice, our staff may call the organisation that performed the tests to receive a fax copy. Your records and information may be kept by your doctor at another location. Your information may be used for billing purposes including bad debt management. If you do not give permission for the above please let our receptionist know. Access to your medical records may be allowed in accordance with the appropriate section of the National Privacy Act 1988.

Your personal information will be 100% secure with us. All the information filled in this form is protected and secure certified.

Patient Information Privacy Form

General Details

Financial Details

Referral Details

Important Information