Terrace Eye Centre New Patient Form

Privacy statement
In providing you with the best possible health care we need to collect and use your personal information for administrative and billing purpose. This may be used for disclosure to others involved in your health care, including other practitioners outside of Terrace Eye Centre, for research and quality assurance, and in emergency situations for treatment purposes. We must comply with laws relating to the collection and use of your personal information, and a full 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:

Consent
I accept responsibility for any associated fees as a result of seeing a doctor at Terrace Eye Centre and it is my responsibility to pay all accounts if my health fund declines payment. I have been informed of the fees for the consultation and any scans. I understand that all accounts are my responsibility. To the extent permitted by law, you agree to pay any expenses incurred by The Terrace Eye Centre in collecting any outstanding accounts due. I understand the reasons why my information must be collected and am aware Terrace Eye Centre has a privacy policy on handling patient information and a copy is available upon request. I understand that I am not obliged to provide my consent to the
Terrace Eye Centre handling my information for the purposes set out above.
I Consent to the use of e-mail communications and I am aware of the privacy risks of use of unencrypted e-mail communications.*

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Date*

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NEW PATIENT– PRIVATE & CONFIDENTIAL