NEW PATIENT INFORMATION

PATIENT DETAILS

Title *

Surname *

First Name *

Middle Name

Preferred Name

Home Phone

Work Phone

Mobile *

Date of Birth *

Email Address *

Street Address *

Suburb *

State *

Postcode *

Medicare *

Yes, I have MedicareNo, I do not have Medicare

Medicare Card No. *

Medicare Reference No. *

Expiry Date *

DVA / Pension / Health Card No.

DVA Card Type

Card Expiry Date

How did you hear about us? *

I agree to communicate and receive necessary reports / documents requested by email

YesNo - collect in person

SECONDARY / EMERGENCY CONTACT (Other than the mobile number above)

Full Name *

Relationship to patient *

Mobile (emergency / secondary contact) *

MEDICARE ACCOUNT HOLDER'S DETAILS (person making a payment and receiving Medicare rebate for the patient)

** Full Name (Account Holder)

Medicare No. (Account Holder)

Medicare Ref No. (Account Holder)

Medicare Expiry (Account Holder) *

Date of Birth (Account Holder)

Relationship to patient (Account Holder)

REFERRAL DETAILS (GP's referral - valid for 12mo, Specialist's referral - valid for 3mo)

Referring Doctor *

This is my usual GP *

YesNo

This is a Medical Specialist *

YesNo

Referring Doctor or Usual GP's Phone No.

Usual GP *

Doctor's Specialty (if not GP) *

Are there any other medical practitioners to whom you would like correspondence sent, in addition to your referring doctor and your usual GP? If so, please list them:

Doctor's Name (1)

Practice Name (1)

Address (1)

Phone No. (1)

Doctor's Name (2)

Practice Name (2)

Address (2)

Phone No. (2)

Doctor's Name (3)

Practice Name (3)

Address (3)

Phone No. (3)

Doctor's Name (4)

Practice Name (4)

Address (4)

Phone No. (4)

CONSENT TO COLLECT PATIENT INFORMATION & PAYMENT

Northern Beaches Immunology & Allergy collects information from you for the primary purpose of providing quality health care. We require you to provide your personal details and a full medical history so that we may properly assess, diagnose, and treat illnesses, and be proactive in your health care. We will also use the information you provide in the following ways:

Administrative purposes in running our medical practice
Billing purposes and compliance with Medicare and Health Insurance Commission requirements
Medicare assignment of benefits to the doctor and claiming the patient’s rebate
Hospital inpatient and outpatient services claim
Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice, and electronic prescription delivery service/s
If I have My Health Record, it may be accessed during my treatment, and registered health care practitioners may upload information at the practice

Patient Consent Acknowledgement

By signing this form, I acknowledge:

I have read the information above and understand the reasons why my information must be collected.
I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment I receive.
I am aware of my right to access the information collected about me, except in circumstances where access might be legitimately withheld. I understand that I will be explained these circumstances. If I request access to information about me, the practice may charge fees to cover time and administrative costs, which a Medicare rebate may not cover.
I understand that if my information is to be used for any purpose other than set out above, my further consent will be sought.
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 that I notify this practice of.
I understand that if I wish to obtain a copy or access to my medical records, the request must be made in writing and may incur a cost.
I consent to the assignment of Medicare benefits to the doctor for all video or telephone consultations, unless I am privately billed with a gap.

Please note that FULL PAYMENT is required ON THE DAY of your consultation. I understand that payment for the consultation and all tests is required in FULL on the day of the appointment. *

Full Name of the person signing this form *

How related to patient as signing this form *

Please sign here (Draw Signature) *

Clear

Signed Date *

Upload your referral & other relevant documents (hospital discharge summary, test results, etc)

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Please bring the original referral to the appointment if the uploaded files are picture taken images