New Patient Form Step 1 of 5 - Practice Location 0% Providence Medical Group All patient information is considered private and confidential and is only accessible to authorised staff members. As required by the Privacy Act 1998 (Cth), we need to know if at any time someone else may be collecting personal information for yourself, i.e. picking up prescriptions and referrals. If this is something you may need to do, please ask one of our receptionists for a form to complete.Select Practice Location*Select Practice LocationBelmontWarners BayThorntonShoal Bay & Anna BayGregory HillsNon-bulk billing practice Personal InformationSurname*First name*Middle nameSalutation*SalutationMrMrsMsMissMasterPreferred nameSex*SexMaleFemaleOtherUnknownDate of birth* Date Format: DD slash MM slash YYYY Ethnicity (Country of origin)*Do you consider yourself to be of Aboriginal or Torres Straight Islander?*NoYes, AboriginalYes, Torres Straight IslanderYes, bothAddress* Street Address Suburb Postcode Email Mobile number*Home numberWork numberOccupationDo not wish to disclose Do not wish to disclose ReligionDo not wish to disclose Do not wish to disclose I have opted out of “My Health Record"*YesNo Card DetailsMedicare numberReference numberExpiry dateDo you have a concession card?*YesNoConcession Card Pension card Health Care Card Commonwealth Seniors Health Card DVA Card Pension Card numberPension Card Expiry dateHealth Care Card NumberHealth Care Card Expiry dateCommonwealth Seniors Health Card numberCommonwealth Seniors Health Card Expiry dateDVA numberDVA Card Expiry dateHEAD OF FAMILY – to be completed for a child 15 years and underNameDate of birth Date Format: DD slash MM slash YYYY Medicare number same as patient?Medicare number same as patient?YesNoMedicare number*Reference number*Expiry date*Next of KinSurname*First name*Relationship*Contact number*Emergency contact person different from next of kin?*YesNoSurname*First name*Relationship*Contact number* Medical HistoryMedical Conditions Asthma Heart Disease Diabetes Mental Illness Hypertension Cancer Operations Other What operations have you undergone?*What other medical conditions do you have?*Do you have allergies?*YesNoAllergies*Have you had the Tetanus immunisation?*YesNoTetanus immunisation date* Date Format: DD slash MM slash YYYY Is your child's immunisations up to date? (If completing for a child )YesNoCurrent Medications ( including over the counter medicines, vitamins and minerals )*Social History Tobacco Alcohol Number per day (tobacco)*Number per day (alcohol)*Females Pap Smear Breast Exam Pap Smear Date* Date Format: DD slash MM slash YYYY Breast Exam Date* Date Format: DD slash MM slash YYYY Overall check-up date Date Format: DD slash MM slash YYYY Consent* I confirm all information detailed in this form is true and correct to the best of my knowledge and will be used by the general practice in the provision of my healthcare.* Patient Consent This general 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 and treat illnesses and medical conditions, ensuring we are proactive in your health care. To enable ongoing care, and in keeping with the Privacy Act 1988 and Australian Privacy Principles, we wish to provide you with sufficient information on how your personal information may be used or disclosed and record your consent or restrictions to this consent. Your personal information will only be used for the purposes for which it was collected or as otherwise permitted by law, and we respect your right to determine how your information is used or disclosed. The information we collect may be collected by a number of different methods and examples may include: medical test results, notes from consultations, Medicare details, data collected from observations and conversations with you, and details obtained from other health care providers (e.g. specialist correspondence). As a general practice committed to providing quality healthcare, we have implemented technology solutions to enable communication with our patients via SMS. As part of our Healthcare services to you, we will send you appointment reminders, clinical reminders and clinical communications from time to time. We may also send you Health Awareness information if you have consented to receive such communications. To the extent that is practicable, we will send you communications via your preferred contact method indicated below. However, you acknowledge that we may contact you using any of your contact details that you may provide us from time to time to consider appropriate. By signing below, you (as a patient/parent/guardian) are consenting to the collection of your personal information, and that it may be used or disclosed by the practice for the following purposes: Administrative purposes in running our general practice. Billing purposes, including compliance with Medicare 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. Accreditation and quality assurance activities to improve individual and community health care and practice management. For legal related disclosure as required by a court of law. For the purposes of research only where de-identified information is used. To allow medical students and staff to participate in medical training/teaching using only de-identified information. To comply with any legislative or regulatory requirements e.g. notifiable diseases. For use when seeking treatment by other doctors in this practice. Health Awareness communications – communications to you in relation to general health care information and services provided by this general practice. At all times, we are required to ensure your details are treated with the utmost confidentiality. Your records are very important, and we will take all steps necessary to ensure they remain confidential. Please complete the consents below if you understand and agree to the following statements in relation to our use, collection, privacy and disclosure of your patient information. Consent for Information Collection* I have read the information above and understand the reasons why my information must be collected, and the purposes for which my information may be used or disclosed. I understand that if my information is to be used for any purpose other than that set out above, my further consent will be obtained.*Consent for Information Disclosure* I give my permission for my personal information to be collected, used and disclosed as described above. I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.*Consent For Communication I wish to receive health awareness communications (as described above) and I hereby specifically consent to the use of my personal information by this general practice to assess the types of health awareness communication it send me and specifically consent to receipt of such health awareness communications.Preferred contact method for all communications* Phone/Mobile SMS Email Letter Consent of Acknowledgement* I acknowledge that the practice will use contact details provided by me (as updated by me from time to time) to communicate with me. To the extent that the mobile number I have provided to this general practice is utilised by more than one patient, I understand and consent that all SSM and phone commutations will be directed to that number.* Check out doctor’s schedule. Make an appointment today at one of our locations. Book Online Now
