PATIENT DETAILS:

EMERGENCY CONTACT:

IF APPLICABLE:

GP / OPTOMETRIST / OTHER SPECIALIST'S DETAILS

This is important to that we can communicate with others involved in your care

OCT SCAN INFORMED CONSENT

You may need an OCT (Optical Coherence Tomography) scan to be performed based on your medical history to enable the specialist to diagnose any problems with your retina. This will not be covered by Medicare.

Private $130               Pension $100

I have been informed of the cost of the OCT which is additional to the consultation.

CONSENT TO COLLECTION OF PERSONAL INFORMATION

Collection of Personal Information, Privacy Act 1988 and HRIP Act 2002 (NSW)

Retina Associates – Eastern Suburbs Retina collects information from you for the primary purpose of providing quality healthcare. We require you to provide us with your personal details and a full medical history so that we may properly assist, diagnose and treat illnesses and so that we may be pro-active in your healthcare. We may also 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 healthcare, including treating doctors and specialists outside this medical practice
• Disclosure to other doctors in the practice, locums and registrars attached to this practice for teaching purposes
  • Please let us know if you do not want your records accessed for this purpose, and we will note this in your record accordingly
• Disclosure for research and quality assurance activities to improve individual and community healthcare and practice management
  • You will be informed when such activities are being conducted, and given the opportunity to opt-out of any involvement
• Receiving quarterly newsletter/reports via email
  • If you have ticked the consent box on the prior page you will be added to our subscription. If you wish to unsubscribe please notify one of our staff. Please let us know if you have any further questions.

I have read the information above and understand the reasons why my information may be collected. I understand that I am not obliged to provide any information requested of me, but that my failure to do so may compromise the quality of healthcare and treatment given to me.

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 given an explanation in these circumstances. I understand that if I request access to information about me, the practice is entitled to charge fees to cover the time and administrative costs, which may not be covered by a Medicare rebate.

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 my information is to be used for any purpose other than that set out above, further consent will be obtained.

COSTS ARE PAYABLE AT THE TIME OF CONSULTATION. ADDITIONAL TESTS MAY BE PERFORMED WHICH WILL INCUR AN EXTRA FEE.

The costs will be discussed with you prior to commencement of tests or treatment. I accept to pay on the day, for all services received, regardless of insurance coverage.

Please note the average length of appointments is 1 ½ - 2 hours. We appreciate your patience.

I have read and understood the information above.

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