Patient Registration Form

Date of Appointment

Title

First Name

Surname

Date of Birth

Street Address

Postcode

Phone

Mobile

Country

(###)

###

####

Do you agree to have SMS reminders or patient information sent to your mobile phone? Tick your response.

AGREE

DISAGREE

Home Phone

Work Phone

Do you agree to email correspondence using the email provided? Tick your response.

AGREE

DISAGREE

Occupation

Medicare Number (10 digits)

Reference Number

Expiry Date

Health Care Card

Expiry Date

Private Health Fund

Pension Card Number

Health Fund Number

Hospital Cover?

Veteran's Affairs Gold Card Number

Emergency Contact

Contact Phone for Emergency Contact

Relationship to Patient

Do you consent to us giving this person your results and appointment information?

YES

General Practitioner (GP)

General Practitioner (GP)'s Address

Referring Doctor

Referring Doctor Address

This clinic collects information from you for the primary purpose of providing quality health care. We handle your personal and health information in accordance with the Privacy Act 1988 (Cth), the Australian Privacy Principles and the Health Records and Information Privacy Act 2002 (NSW) (referred to as the Privacy Laws). 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 a number of ways including the following: - Administrative 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 or staff 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. Federal Privacy Law requires your consent to this. A copy of the full privacy policy is accessible on the website www.drvictoriabuckley.com.au under ‘Patients’ (https://www.drvictoriabuckley.com.au/patients) or in hard copy from reception.

CONSENT

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 understand that if my information is to be used for any purpose other than those listed in the privacy policy, this clinic will seek my consent prior I consent to this clinic using my personal information in the ways outlined in the privacy policy I understand that consultations are not bulk billed &/or not payable by private health insurance, and fees are payable on the day of consultation. Initial consultations incur a fee of $330 with a Medicare rebate of approximately $84.15. Subsequent consultations within the referral period will be $180 with a Medicare rebate of approximately $42.30. Fees are reviewed annually. Any missed appointment or cancellation with less than 24 hours notice may incur a fee. It is your responsibility to ensure your referral is current prior to all consultations. I also understand that if there is a need for a procedure or treatment, there will be additional fee for these. Specimens (blood tests, smears, Thin Prep, biopsy, urine test, swabs etc) are sent to DHM pathology and you will receive a pathology invoice, part of which is claimable by Medicare.

Acknowledgement and Consent to Privacy Policy

I AGREE AND CONSENT TO THE ABOVE

Patient Registration Form

Phone
02 9557 2450

Fax
02 9550 6257

Address
Suite 404 RPAH Medical Centre
100 Carillon Avenue
Newtown, NSW 2042

Patient Registration Form

Phone02 9557 2450Fax02 9550 6257

AddressSuite 404 RPAH Medical Centre100 Carillon AvenueNewtown, NSW 2042

Phone
02 9557 2450

Fax
02 9550 6257

Address
Suite 404 RPAH Medical Centre
100 Carillon Avenue
Newtown, NSW 2042