Patient Registration

AGPAL
02 9687 4000

    Title *

    Date of Birth *

    Given name (first name) *

    Surname (last name) *

    Address *

    Suburb *

    Post Code *

    Home Phone

    Work Phone

    Mobile Phone *

    Email *

    Patient Medicare No

    Num Beside Name

    Exp

    Or Department of Vet Affairs File No

    Card Colour

    Pension / Concession No

    Exp

    Marital Status

    Occupation

    Ethnicity (Background)

    Country Born

    Language Spoken

    Are you Aboriginal or Torres Strait Island?
    NOYES

    Emergency Contact Name

    Relationship

    Emergency Contact Phone Number

    How did you hear about us?

    Allergies

    Smoking

    Family History

    Do you consent to receive information regarding our practice services? Yes

    Privacy Statement

    The Health Records and Information Privacy Act 2002 require medical practitioners to obtain consent from their patients to collect, use and disclose the patient’s personal information.

    Collection – this means that we will collect information that is necessary to properly advise and treat you. Such necessary information may include:

    • Full Medical History

    • Ethnicity

    • Medicare details

    • Genetic information

    • Family medical history

    • Contact details

    • Private health fund details

    • Billing / account details

    The information will normally be collected directly from you. There may be occasions when we will need to obtain information from other sources, for example:

    • Other medical practitioners, such as former GPs and specialists

    • Other health care providers, such as psychologists, physiotherapists, dentist, nurses, chemists

    • Hospitals or day surgery units

    • Pathology and radiology practices

    All our staff may participate in the collection of this information. In emergency situations we may need to collect personal information from relatives or other sources where we are unable to obtain your prior express consent.

    Use and Disclosure – with your consent, your information will be used and disclosed for purposes such as:

    • Account keeping and billing from/for Westmead Doctors

    • Referral to another medical practitioners or health care provider

    • Claiming from Medicare and your health fund on your behalf when required

    • Sending of specimens, such as blood or tissue samples for analysis

    • Referral to a hospital for treatment is advisable

    • The management of our practice in relation to bookkeeping, debt collection & taxation audit

    • Quality assurance, including development of a database for surveillance of patient treatment outcomes, accreditation, complain handling and audits

    • To meet our legal obligations of notification to Westmead Doctors and our providers medical indemnity insurers

    • To prevent or lessen a serious threat to Public Health or safety where legally required to do so, such as producing records to court, mandatory reporting of child abuse or the notification of diagnosis of certain communicable diseases

    • For medical student training where your de-identified medical information and age (not your name, address or phone number) would only be used for research projects and training of medical students

    • For medical research projects complying with strict protocols and approved by a Human Research & Ethics Committee – YOU WILL BE PROVIDED WITH SEPARATE INFORMATION SHEETS AND CONSENT FORMS TO READ AND SIGN.

    CONSENT

    • I hereby provide my consent to Westmead Doctors and staff to collect, use and disclose my personal information as outlined above (except where you have deleted where applicable to your removal of consent).

    • I understand that I am entitled to access my own health records except where access would be considered unreasonable.

    • Apart from other doctors and health care providers associated with my health care, I hereby permit my condition to be discussed with the following people (e.g. spouse, family member, friend) and may add/withdraw my consent in writing to add/remove same:

    Name

    Name

    Name

    Name

    I understand I may withdraw my consent as to the use and disclosure of my personal information (except where legal obligations must be met).

    Patient Signature

    Date

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