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reception@entnorth.com.au
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Our Team
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Information
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Contact
Patient Registration
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Patient Registration
1
Your Details
2
Medicare & Other Cards
3
Your GP & Emergency Contact
4
Communication
5
Privacy & Consent
Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Prefix
First
Last
Date of Birth
*
DD dash MM dash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
Post Code
Phone (H)
*
Phone (W)
Phone (Mobile)
Marriage Status
Single
Married
Defacto
Divorced
Widowed
Email
Medicare Card Number
Medicare Reference Number
*
Please enter a number from
0
to
20
.
Medicare Expiry
*
MM/YYYY
Do you have Private Health Insurance?
*
Yes
No
(Hospital Cover Only)
Name of Fund
Membership Number
Have you been fully vaccinated against COVID-19?
*
Yes
No
Do you have a BLUE Pension Card?
*
Yes
No
Pension Number
Do you have a Veterans Health Card?
*
Yes
No
Veterans Affairs Number
Colour of Card
Gold
White
Orange
Other
Please specify type of card
Your usual General Practitioner
Name
Dr.
Prefix
First
Last
GP Address
Street Address
Address Line 2
City
State / Province / Region
Post Code
GP Phone
Person responsible for the account IF other than the patient
Name
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Prefix
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
Post Code
Date of Birth
MM slash DD slash YYYY
Medicare Reference Number
Emergency Contact
Name
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Prefix
First
Last
Emergency Contact Address
Street Address
Address Line 2
City
State / Province / Region
Post Code
Relationship To You
Phone (H)
Phone (W)
Phone (M)
Are you happy if we communicate with you by SMS?
Yes
No
Are you happy for us to email your results where appropriate?
Yes
No
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 either for a particular event or generally. This form explains your rights in relation to the use of the information and, how we may disclose it to other medical service providers. The information we ask you to give us is deeply personal. However, not having it will restrict our capacity to provide you with the standard of medical care that you expect. Please carefully read the following information about privacy issues and then sign this form. It will go on your file and you may examine it or change it at any time. We collect information from you mainly to assess, diagnose and treat your illness properly and be pro-active in your health care. We will also use the information you provide in the following ways: · Administration of this medical practice; · Billing, including compliance with Medicare and Health Insurance Commission requirements; · Disclosure to others involved in your 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 returned to us following the referrals. If necessary, we will discuss this with you; · Disclosure to other doctors in the practice and locums if required.
Patient Acknowledgement
I have read this form and understand why collecting information about me is necessary. I am also aware that this practice has a privacy policy for managing patient information. I understand that I am not obliged to provide any information requested of me. I also understand that failure to provide this medical practice with all the information it needs may restrict the ability to provide the quality of health care and treatment that I require. 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 understand that if my information is to be used for any purpose other than that set out above, my permission, in writing, will be sought before any action is taken. 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.
CONSENT FOR RELEASE OR ACQUISITION OF MEDICAL INFORMATION/RECORDS
I hereby give my permission for Dr Amott or Dr Yuen to either release or request any medical information/records relevant to me as required.
Do you agree to all above
Yes
No
Dated
DD slash MM slash YYYY
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