Patient Information Sheet printable pdf download

PATIENT INFORMATION SHEET

TO BE COMPLETED IN FULL BY THE PATIENT OR GUARDIAN

If patient is under the age of 16 years, please also provide carer/parental details

PATIENT DETAILS:

Mr Mrs Miss Master Other:

SURNAME/FAMILY NAME

FIRST NAME

Address:

Email:

Phone Home:

(

)

Mobile:

Date of Birth:

_______/_______/_______

Any Allergies:

Yes No

Details:

Medicare No:

Position on Card: 1 2 3 4 5

Expiry Date:

Private Health Insurance Fund Name:

Membership Number:

Veterans Affairs Card Number:

Card Colour:

Parent/Carer/Guardian details:

NAME:

Circle ONE

Address:

Phone Home:

(

)

Mobile:

REFERRED BY:

Referral Date:

Referring Doctor’s Address:

YOUR GP:

Phone:

(

)

GP’s address:

This is required even if you have been referred by another Doctor)

PRIVACY INFORMATION AND CONSENT FORM

The law gives you certain privacy rights in relation to information that you give to this medical practice. We need your consent to collect personal information

about you. The fact that you have come here implies that you consent to us knowing about your health situation. The information we may ask you to give us is

personal, but not having it will restrict our capacity to provide you with the standard of medical care that you expect.

Please read carefully the following information about privacy issues then sign this form where indicated below.

The reason we collect information from you is so we can assess, diagnose and treat your illness properly and be pro-active in your health care. We may also

use the information you provide in the following ways:

Administration of this medical practice.

Billing, including compliance with Medicare and H.I.C requirements.

Disclosure to others involved in your health care, including doctors and specialists outside this practice who may become involved in treating you. This

may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals.

Disclosure to others for medical defence purposes if necessary.

Disclosure to other doctors in the practice, locums and Registrars attached to the practice for the purpose of patient care.

Disclosure for quality assurance and research activities to improve individual and community health care and practice management. You will be informed

when such activities are being conducted. You may decline to have any involvement.

Patient’s / Guardian’s Acknowledgment:

I have read this form and understand why collecting information about me is necessary.

I understand I am not obliged to provide any information requested of me, but that failure to provide this medical practice with all the information it needs may

restrict the practice’s ability to provide the quality of health care and treatment that I want.

I am aware that I have the right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I

understand I will be given an explanation in these circumstances.

I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure about which I notify

this practice now or at any future time.

I acknowledge that I have read this form before signing it and that a member of staff of this practice has at my request clarified any aspects of it that I did not at

first understand.

Signed

Date

officeadmin:Clinical Doc Templates:2_Patient Information Sheet_P1_Master.docx

Patient Information Sheet

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