New Patient Registration Form

New Patient Registration Form
A Personal Details
Title  Mr  Mast  Mrs  Ms  Miss  Dr  Other
Given Name
Middle Name
Preferred Name
Date of Birth
Last Name
Gender  Male  Female
Medicare Number
Reference Number
Expiry Date
Work Phone
Mobile
Postal Address
Home Phone
Email Address
Do you wish to identify yourself as an Aboriginal or Torres Strait Islander?  Yes  No
B Concessions
Pension Number
HCC
Expiry Date
DVA
C Emergency Contact
Next of Kin
Relationship
Phone
Emergency Contact Name
Relationship
Phone
D Ethnicity
Country of Birth
Year of Arrival in Australia
Ethnicity (Culture, Origin)
Spoken Language
E Health Information
Allergies or Sensitivities
Medical Conditions or Disabilities
Childhood Immunisation completed?  Yes  No
Are you an overseas student with a BUPA Card?  Yes  No
Year of last tetanus injection
BUPA No.
Expiry Date
Do you require an interpreter?  Yes  No If so, language required _____________________________________________________
F
Authorisation
Would you like to receive reminders about periodic health checks, e.g. diabetic reviews, immunisations, pap smears etc.  Yes  No
Are you happy for us to send you reminders via SMS?  Yes  No
How did you hear about us?  Word of Mouth  Google  Our Website  Health Engine  Flyer  Other ________________
Signature
Westwood Medical Centre ABN 71 220 877 472
Date
Please turn over and fill in the back page
Health Information Collection & Use Consent Form
As a patient of our medical practice we require you to provide us with your personal details and a full medical history, so that we may properly assess,
diagnose, treat and be proactive in your health care needs.
We aim to protect the privacy and secure storage of 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.
We require your consent to collect personal information about you and to use the information you provide in the following ways. Please read this
consent form carefully, and sign where indicated below.
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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, Allied Health Professionals and specialists outside this medical
practice. This may occur though referral to other doctors, or for medical tests and in the reports or results returned to us following referrals.
Disclosure to other doctors in the practice, locums and Allied Health Professionals etc. 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 will identify you be required you will be informed and given the opportunity to
“opt out” of any involvement.
To comply with any legislative or regulatory requirements e.g. notifiable diseases.
For reminder letters which may be sent to you regarding your health care and management.
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 provide the best outcome for you.
I have read the information above and understand the reasons why my information must be collected.
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I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the quality of health
care and treatment given to me.
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I am aware of my rights to access the information collected about me, except in some circumstances where access may be legitimately
withheld. I will be given an explanation in these circumstances.
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I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.
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I understand that depending on the age of my child (16 and over) and given my child’s right to privacy, in the clinical judgement of the
doctor treating my child I may be prevented from access to information regarding my child’s healthcare.
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I consent to the handling of my information by the practice for the purpose set out above, subject to any limitations on access or
disclosure of which I notify this practice.
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OR
I am unsure and would like to discuss this further with someone from the medical practice before I sign.
Patient’s Name
Patient’s Signature
Date
Signed as guardian for child
Name (Printed)
Westwood Medical Centre ABN 71 220 877 472
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