New Patient Form

Opt out of SMS reminders

Ethnicity: Do you identify as AboriginalTorries Straight IslanderBothNeither

If yes, are you registered for Closing the Gap (CTG)?YesNo

Do you require an interpreter? (Ph 131540) Yes

IN CASE OF EMERGENCY(if different to next of kin)

How did you find us?Family/FriendsOur websiteSocial MedicalOther

Health Information Collection and Use Consent – please read carefully before you sign

Why and how we collect and use your personal information.

As a patient of our medical practice, we require your personal details and a full medical history in order to properly assess, diagnose, treat and be proactive in your health care. We aim to protect the privacy and securely store your health information. You can request a copy of our privacy policy, which includes information about the collection, use and disclosure of your health information.

This practice will use and/or disclose your information for the following:

• Administrative purposes in running our medical practice.

• Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.

• Disclosure to others involved in your healthcare including treating doctors, specialists, nurses and allied health professionals outside this medical practice. This may occur though referral to other medical providers or for medical tests, as well as in the reports or results returned to us following referrals.

• Disclosure to other medical professionals in the practice including locums attached to the practice for the purpose of patient care and teaching.

• For research and quality assurance activities to improve individual and community health care and practice management. Usually, information that does not identify you is used but should information that may identify you be required you will be informed and given the opportunity to opt out of any involvement.

• To your employer in the case of employment or pre-employment health checks and to their insurance providers in the case of workers’ compensation claims.

• To comply with any legislative or regulatory requirements e.g. notifiable diseases.

• For follow-up recalls and/or reminder letters for treatment and preventative health. This may be done by mail, phone, or SMS.

I give permission for next of Kin/Emergency contact/Partner to obtain personal information on my behalf:YesNo

You can decline to have your health information used in all or some of the ways outlined above but it may influence our ability to manage your health care to the highest standards.

I have read and I understand this form.

By signing below, I consent to the collection and use of my information by the practice for the purposes set out above, subject to any limitations on access or disclosure of which I will notify this practice.

I am unsure and would like to discuss this further with someone from the practice before I sign.

Signature: