Terrace Eye Centre New Patient Form

Terrace Eye Centre New Patient Form

NEW PATIENT– PRIVATE & CONFIDENTIAL
- Full Name*
  
  TitleFirst nameLast namePreferred name
- Date of birth
  
  DayMonthYear
  Date
- Gender
  
  FemaleMaleI prefer not to say
- Occupation
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Post codeCountry
- Mobile number*
- Home number
- Work number
- E-mail*
- GP details
  
  Name
  
  Practice Name/Suburb
  
  Phone numberState
  
  Post code
- Optometrist details
  
  Name
  
  Practice Name/Suburb
  
  Phone numberState
  
  Post code
- Other Specialist details
  
  Name
  
  Practice Name/Suburb
  
  Phone numberState
  
  Post code
- Next of kin
  
  Name
  
  Relationship
  
  Phone numberState
  
  Post code
- Are you Aboriginal or Torres Strait Islander Origin?
  
  YesNo
- Do any Guardianship Orders apply?
  
  YesNo
- If patient is a child are there any Parenting Orders in place?
  
  YesNo
- I authorise you to contact Medicare on my behalf
  
  YesNo
- I consent to telehealth calls and billing on my behalf to Medicare as required
  
  YesNo
- Medicare
- Dept of Vet Affairs
- Pension card
- Private health fund
- Work cover claim
- Defence PM Keys
- At Terrace Eye Centre, we are committed to providing you with the highest standard of care. To support this, we need to collect and use certain personal information about you. This information is used for administrative and billing purposes and may be disclosed to others involved in your healthcare — including referring doctors, specialists, and other practitioners outside of Terrace Eye Centre. In some cases, clinical photographs and scans may be taken as part of your medical assessment, diagnosis, or treatment. These images form part of your confidential medical record. These photographs and scans may be used for clinical education, research or training purposes, unless you choose to opt out.
  
  We are committed to protecting your privacy in accordance with applicable laws; a full copy of our privacy policy is available on request.
- Please tick acceptable methods of communication:
  
  Mobile/SMSHome phoneMailEmail
- Family member with whom the doctor can speak to regarding your condition:
  Name
- Copy Reports to Medical Practitioners:
- Full Name
  
  TitleFirst nameLast namePreferred name
- Date of birth
  
  DayMonthYear
  Date
- Relationship to patient
- Medicare
- Address (if different to above)
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Post code
- Phone number
- By signing this form, you acknowledge and provide consent for the following:
  
  • The collection, use, and disclosure of your personal information as outlined above
  • The sharing of relevant health information with other healthcare providers involved in your care
  • Clinical photographs to be taken and stored as part of your medical record, and used for education or training in a de-identified form unless you request otherwise
  By signing this form, you acknowledge and agree to the following:
  
  • You are aware of and agree to the consultation and procedure fees, which have been explained to you
  • You accept financial responsibility for all fees associated with your consultation, diagnostic imaging, pathology, and/or treatment at Terrace Eye Centre
  • You understand that if your private health fund or insurer declines to pay, you are liable for the full account
  • To the extent permitted by law, you agree to pay any reasonable expenses incurred by Terrace Eye Centre in recovering outstanding payments e.g. debt collector fees
- I have read and understood the Privacy Statement and Financial Consent provided above. I consent to communication via phone, email, SMS, and/or mail for the purposes of providing health-related information and managing administrative matters. I acknowledge and accept the privacy risks associated with the use of unencrypted email communication.*
  
  YesNo
- Signature*
  
  Clear
- Date*
  
  DayMonthYear
  Date
- Should be Empty: