Patient Information and Consent Form

  • We encourage you to complete the form below, and press the “submit button”.
  • If you prefer, you may print this form and bring it to your appointment.
  • This form is not an appointment request, please phone 3831 4382 and select option 1 to set up an appointment before you complete this form.
Patient Information and Consent Form
Title *
Street address *
Street address
Postal address (if different to above)
Postal address (if different to above)
Gold card
Pension or healthcare card
Private health fund
Consent *
Cancellation fee *

As a consequence of the new Federal Law on Privacy, we require your consent to collect personal information.

  • If you send this form electronically, then you are consenting to the following terms and conditions.
  • Alternatively you may print, complete and bring this form with you to your appointment.

This medical practice collects information from you for the primary purpose of providing your health care. 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:

  • Administrative purposes in running the practice which may also include confirmation of your appointment via SMS texting or email.
  • Sending of your results of investigations to you via SMS or email.
  • Billing and collection purposes, including but not limited to compliance with Private Health Fund, Medicare, Workcover and 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.
  • Disclosure for research and quality assurance activities. All data will be anonymous and comply with NHMRC guidelines.
  • Emergency situations whereby medical officers/hospitals may require access to patient notes for treatment purposes.
  • Legal disclosure.
  1. I have read the information above and understand the reasons why information must be collected. I am also aware that this practice has a privacy policy which can be reviewed if requested.
  2. I understand that I am not obliged to provide all information requested of me.
  3. I am aware of my rights to access the information collected about me in most circumstances.
  4. I understand that if information is to be used for any purpose other than set out above, my further consent would be required.
  5. 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.