Surname
First Name
Title
Mr
Mrs
Ms
Miss
Dr
Prof
Sir
Lady
Br
Sr
Mx
Other
If Other
Birth Sex
Female
Male
Other
Prefer not to Answer
Gender Identity
Female
Male
Non-binary
Gender-diverse
Transgender
Different Identity
Prefer not to Answer
Pronouns
She/Her/Hers
He/Him/His
They/Them/Theirs
Prefer not to Answer
Date of Birth
Occupation
If you answer 'Other' above, please specify
Preferred Language
Other Languages
Address
Suburb
Postcode
Contact Numbers
Please provide at least ONE number.
Home
Mobile
Email
Please only choose ONE - this can be changed at any future appointment.
By submitting this form,you consent to receiving SMS reminders, (email as applicable) communications relating to appointments, clinical information and results.
Please note: This is not to be used as your only reminder.
If you require any special consideration or assistance based on your cultural background please elaborate:
Next of Kin
First Name
Surname
Contact Number
Relationship to You
Emergency Contact
This is compulsory and can be the same as Next of Kin.
First Name
Surname
Contact Number
Relationship to You
Allergy Information
Do you have any allergies or are you sensitive to drugs or dressings?
Current Medications
Please list all your current medications, including complementary and over-the-counter medicines (e.g. homeopathic medicines such as vitamins and minerals etc.)
Medical History
If you have had surgery or selected Other, please provide details:
Lifestyle Risk Factor Information
If you're a smoker, how many cigarettes per day and which year did you start?
If you're an Ex Smoker, how many cigarettes did you smoke a day and which year did you start and stopped?
If you're a drinker, how many days per week do you drink and how many standard drinks per day?
If yes, please specify type of drug and frequency
Family Health History Information
Please provide details if any family member has cancer or other significant illness
Date of last check up
If Applicable:
Date of last Cervical Smear
Date of last Mammogram
Please note: Some of our Drs/Nurses use an AI scribe during consults. This will not be done without your consent and no recordings are stored. Please ask at reception if you would like a patient information sheet.
Health Information Collection and Use and Disclosure Patient Consent Form
This general practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose and treat illnesses and medical conditions, ensuring we are proactive in your health care. To enable ongoing care, and in keeping with the Privacy Act 1988 and Australian Privacy Principles, we wish to provide you with sufficient information on how your personal information may be used or disclosed; we will record your consent or restrictions to this consent.
Your personal information will only be used for the purposes for which it was collected or as otherwise permitted by law, and we respect your right to determine how your information is used or disclosed.
The information we collect may be collected by a number of different methods, and may include, but not limited to: medical test results, notes from consultations, Medicare details, data collected from observations and conversations with you, and details obtained from other health care providers (e.g., specialist correspondence).
By submitting this form, you (as a patient/parent/guardian) are consenting to the collection of your personal information, and that it may be used or disclosed by the practice for the following purposes:
Administrative purposes in the operation of our general practice: including but not limited to handling of complaints, Medicare and account queries
Billing purposes, including compliance with Medicare requirements.
Follow-up reminder/recall notices for treatment and preventative healthcare, sent by post, and if consented, by SMS and/or email.
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 or results returned to us following the referrals.
Accreditation and quality assurance activities to improve individual and community health care and practice management.
For legal related disclosure as required by a court of law.
For the purposes of research only where de-identified information is used.
To allow medical students and staff to participate in medical training/teaching using only de-identified information.
To comply with any legislative or regulatory requirements, e.g., notifiable diseases.
For use when seeking treatment by other doctors in this practice.
At all times we are required to ensure your details are treated with the utmost confidentiality. Your records are very important and we will take all steps necessary to ensure they remain confidential.
Please read the information below regarding our collection, use, privacy and disclosure of your patient information. By submitting this form, you confirm the following:
You have read and understood the reasons why your information is collected, and the purposes for which it may be used or disclosed. If your information is to be used for any purpose other than what is set out above, your further consent will be obtained.
By submitting this form, you give permission for your personal information to be collected, used and disclosed as described above, including contact via SMS to your mobile phone number and/or email address . Only your relevant personal information will be provided to allow the above actions to be undertaken, and you are free to withdraw, alter or restrict your consent at any time by notifying this practice in writing.
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