Privacy Statement

(Please read this statement carefully)

Due to Privacy Legislation, we require your consent to collect personal information. This practice collects your information in order to identify your medical record and provide an accurate, quality health service. This means that we will use the information you provide in the following ways:

• Administrative purposes in running a specialist medical practice: including pre-operative and post-operative calls using phone numbers and names you provide us, as well as hospital interaction for booking surgical services.

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

• Disclosure to others involved in your medical care, including treating doctors, specialists, hospital booking staff outside this practice. This may occur through referral to other doctors, surgery at hospitals, for medical tests and in the reports or results returned to us following the referrals.

IMPORTANT:

• I have read the information above and understand the reasons why my information must be collected.

• I am also aware that this practice has a privacy policy on handling patient information.

• I understand that I am not obliged to provide any information requested but failure to do so might compromise the quality of health and treatment provided to me.

• I am aware of my right to access the information collected about me, except in circumstances where access might legitimately be withheld

• I understand I will be given an explanation in these circumstances.

• I understand that if my information is to be used for any other purpose other than that set out above, my further consent will be obtained.

• I consent to the handling of my information by this practice for the purpose set out above, subject to any limitations on access or disclosure that I notify this practice of.

PLEASE NOTE: Due to the privacy laws, results cannot be given to a third party unless written authorization is obtained or under special circumstances.


New Patient Registration Form

Please fill in ALL fields
* Required

Personal Information

Title
First Name *
Last Name *
Email Address *
Home Phone Number *
Cell Phone Number *
Date of Birth *
Home Address *
City *
State *
Zipcode/Postcode *
Country *
 

Next of Kin

First Name
Last Name
Relationship
Contact No.

 Health Fund Information

Medicare No.
Patient Reference No.
Expiry Date
Do you have private health insurance:
Yes
No
Health Fund:
Membership/Policy No.
Patient Reference No.
Expiry Date (if applicable)
Please select your cover
Full hospital cover
Extras only
Hospital and extras
 

Medications

Do you take warfarin?
Yes
No
Are you a diabetic?
Yes
No
if so; are you insulin dependent? 
Yes
No
Do you take plavix?
Yes
No
Do you take any antidepressants? 
Yes
No
If so; which has been prescribed
Allergies
Current Medications
 

Do you have any:

Metal implants?
Yes
No
Pacemaker?
Yes
No
Stents?
Yes
No
Any previous operations/ medical conditions? Please list:
I agree to Surgery Gold coast's Terms of Service and Privacy Policy *
Agree

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