Patient registration

Name*
MM slash DD slash YYYY
Address
* Do you wish to receive automated SMS reminders?
* Do you wish to receive correspondence by email?
(number next to name)

Next of kin

Name*
MM slash DD slash YYYY

Health Records Collection Statement

Your doctor is collecting your health information to provide you with health services. Please read and sign to give consent for your information to be collected and stored.

Your medical information will be used for providing health care in the following way;

  • To obtain medical history, diagnoses, organise medical test and provide treatment
  • Disclosure to your doctor and/or other doctors involved in the provision of healthcare, this includes but not limited to writing correspondence and referral letters, organising medical tests and storing of reports provided to this practice by other doctors
  • Administrative purposes in running this practice
  • Billing purpose, including compliance with Medicare and Health Insurance Commision requirements
  • Disclosure for research, teaching and quality assurance activities to improve healthcare
Consent*
I consent to the collection of my information by this practice for the purposes set out as above.
Name
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.