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Patient Information
Name
*
Mr/Mrs/Miss/Ms/Dr
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
Prefix
First Name
Last Name
Date of Birth
*
DD slash MM slash YYYY
Address
*
Street Address
Address Line 2
State / Province / Region
Postal Code
Home Phone
eg: 61 08 12345678
Work Phone
eg: 61 08 12345678
Mobile
*
eg: 61 04 12345678
Phone
Email
Medicare Number
*
Position on Card
*
Expiry
*
Health Fund
Membership Number
Expiry
(All Patients seen at these rooms need to have full private hospital cover)
DVA Number:
DVA Transport required?
Yes
No
Referring Doctor
*
Family GP
*
Phone
*
Address
Have you previously been an inpatient at Hollywood Hospital?
*
Yes
No
Do you suffer from any infectious disease? (e.g. Hepatitis / HIV / TB)
*
Yes
No
Have you any allergies?
*
Yes
No
Details
*
Do you take: Aspirin / Warfarin / Clexane or any other blood thinning agents?
*
Yes
No
Next of Kin Name
*
Relationship
*
Address
Phone
Mobile
*
Consent Form
*
Its the policy of this Practice to ensure the confidentiality and security of the personal and health information of those attending. It is also the policy of the Practice to abide by the requirements of the Privacy (Private Sector) Amendment Act 2000.
It is necessary to collect personal information form you for the primary purpose of assisting the development of diagnosis, treatment and further advice concerning a particular health condition, suspected health condition or circumstances relating to health. The personal and health information collected will be used in the following areas:
- Administrative purposes in running the medical practice
- Billing purposes, including compliance with the Health Insurance Commission and Department of Veterans’ Affairs requirements.
- Disclosure to others involved in your health care (including treating doctors, specialists and other healthcare professionals outside this medical practice). This may occur through referral to other doctors, referral for medical tests and in the reports of results returned to this practice following referrals.
- Disclosure to medical staff of private hospitals where this will be of importance in the furtherance of your health care.
- Disclosure for research and quality assurance activities to improve individual and community practice.
- Disclosure to legal and insurance inquiries where such evaluations and information is required for the proper conduct, elucidation, and compensation of the matter in hand.
I have read the information provided above and understand the reasons my personal health information is required to be collected. I am also aware that this Practice has a Privacy Policy pertaining to the handling of personal health information of its patients.
I understand that I am not obliged to provide any information requested to me, but that failure to do so might compromise my health care, treatment or – where applicable – the proper evaluation of my disability.
I aware of my right to access the personal and health information collected, except in some circumstances where access might legitimately be withheld. I understand that if my personal information is to be used for any other purpose other than set out above, my further consent will be obtained (unless otherwise ordered by a court of law).
I consent to the handling of my personal health information by Dr Jessica Yin for the purposes set out above, subject to any limitations on access or disclosure that I notify to this practice.
Name
*
Date
*
DD slash MM slash YYYY
Signature
*