PERSONAL INFORMATION

NEXT OF KIN

FINANCIAL INFORMATION

REFERRING DOCTOR

Authority for us to provide your information to necessary health care providers.

I authorise Dr Ghazanfari to provide information about my personal health care to other health care providers for the purpose of optimising my health care management. Dr Ghazanfari will maintain ownership of this information and will release only such information as is deemed relevant for care provision.

Authority to release personal information to us.

I authorise Dr Ghazanfari to obtain all medical and other information required for my care.

I consent to the release of medical, clinical or other information by any medical practitioner, hospital, clinic, insurance company, Centrelink, the Department of Defence or other organisation that would appear to be relevant Dr Ghazanfari.

I understand that by signing this form it will mean that Dr Ghazanfari and his delegates will be able to ask any person who holds information about you to disclose that information, if that information seems relevant to providing my medical care.

In general, this form will be used to access your medical records in the possession of other Doctors and hospitals.

MEDICAL HISTORY

Do you have any of the following (if YES, please tick appropriate box):

FAMILY HISTORY

ALLERGIES

The information listed above enables our Physician to provide the best patient care possible. This information is treated as STRICTLY CONFIDENTIAL and will not be disclosed unless prior consent is obtained from the patient.

HEALTH ASSESSMENT QUESTIONNAIRE (HAQ-DI) ©