Prior to your initial appointment we require your consent to collect personal information about you. Please read this information carefully and sign where indicated at the bottom. Thank you!

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways:

  • Administrative purposes in running our medical practice.
  • Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
  • Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals.
  • As part of internal research and audit reasons, your clinical data may be used for analysis purposes and also for scientific publications. Your personal details will not be shared under any circumstances.

By signing this patient information sheet you acknowledge that:

  1. You have been informed of charges for consultations and the requirement to render payment in full on the day of the consultation.
  2. It is your responsibility to provide a current referral from your Doctor, i.e. GP (lasts 12 months) or Specialist (lasts 3 months). If you do not attend with a current referral, Medicare will not process your refund.

  3. Please be advised that as part of your treatment, our Doctors do not provide medical reports for insurance, medico-legal or other related purposes. Additional charges will apply if you do require such reports
  4. Workcover reports are only furnished in cases where you are identified as a Workcover case prior to making your appointment.

If for any reason you do not agree to the above conditions, alternative arrangement for your care will be made.

I have read the information above and understand the reasons why my information must be collected.

I am also aware that this practice has a privacy policy on handling patient information.

I understand that I am not obliged to provide any information requested, but that my failure to do so might compromise the quality of the health care and treatment given to me.

I am aware of my 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 other purpose other than set out above, my further consent will be obtained.