Patient Registration Form

---

By signing below I consent for you to collect my personal information for medical purposes. I have read and understood the privacy policy and I agree to the fees and charges set out for my consultation and am aware these are payable on the day I am to be seen.

To ensure quality care and practise we will collect personal information from you including but not limited to medicare details, health care provider and medical history. For billing and claiming purposes, we need to collect specific information to be provided to Medicare and Health Insurance Commissions. To ensure the best possible health care, we may also be required to share information you have provided with other health professionals and third parties (e.g., GP’s, Specialists, WorkSafe, TAC and/or Lawyers). By completing this form you give Matt Barnes permission to provide this information upon request, when a signed authority is provided to our rooms.

Alternatively, you can advise us of any information you wish to be kept private but understand this may affect your care. For further information on what data we collect and why, head to our Privacy Policy.

Mr Matt Barnes, use of clinical images policy

Optional consent to use of images (RADIOLOGY, PRE and POST OP Images)

Please read the following information carefully to ensure full understanding of clinical photographic use of your images by Mr Matt Barnes.

It can be highly beneficial to offer realistic and genuine outcomes to patients, positive and negative, who are wanting to proceed with similar surgery to yourself. Mr Barnes or his team may ask you for your permission to use screenshots of your radiology or before and after progress photos for our social media platforms, staff education, marketing or clinical discussions. While verbal consent will be attained prior, written consent is also required before the use of any images. Patients reserve the right to decline the use of clinical images.

All images used will be de-identified; that is any and all identifiable features including pre-existing scars, tattoos, piercings, body markings, name, address, DOB will be removed prior to use.

By signing below you give informed consent to the use of your clinical images in line with Mr Matt Barnes’ image policy as outlined above. This document will be stored in your clinical file only.