New Patient Form

I acknowledge the following: This clinic collects information from you for the primary purpose of providing quality health care. Federal Privacy Law requires your consent to this. We need your personal details and full medical history (which may include photographic records) so that we may properly assess, diagnose, treat and manage your health care needs. This means we will use the information you provide in the following ways:

Adminstrative purposes in running our medical practice, which may include confirmation of your appointment via SMS or email
Billing purposes - including, but not limited to, compliance with Medicare and the Health Insurance Commission requirements
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 of results returned to us following the referrals.
Disclosure to other doctors in the practice, locums and trainees attached to the practice for the purpose of patient care and teaching.
Emergency situations whereby medical officers/hospitals may require access to patient notes for treatment purposes.

I consent to the following:

I have read the above information and understand the reasons why my information must be collected.
I understand that I am not obliged to provide any information requested, but that 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 and that an explanation will be given to me in this circumstance.
I give permission for information relating to my medical condition(s) and treatment to be used for research and audit purposes. When this is done, I understand that my identity will be protected.
I understand that if my information is to be used for any purpose other than the above, this clinic will seek my consent prior.
I consent to this clinic using my personal information in the ways outlined above.
I understand that consultations are not bulk billed &/or not payable by private health insurance, and fees are payable on the day of consultation.
I also understand that if there is a need for a procedure or treatment, there will be additional fee for these.
I understand for security purposes the common area at this clinic is under video surveillance. I understand that my results and clinical information will be communicated from the treating Doctor via primary sms/ email contact provided and that a phone call from clinic staff will follow to plan any associated treatment.

Patient Details

Parent/Guardian Details (If patient is under 18 years old)

Phone: 1300 080 784

Office Hours: 9am – 5pm at all locations

Locations: Richmond - Noble Park - Burwood East - Huntingdale - Elsternwick