Compass Immunology Clinic

Compass Immunology Clinic

General Intake Form
Welcome to Compass Immunology Clinics

Please complete this online form prior to your appointment.

This information greatly assists us to ensure your correct details and improve our communication with you.

Please Note:

* Several consent and policy forms within the intake will require your E-Signature.

* Sustainability is important to us so please do not print these forms. We are a Paperless Practice utilising Electronic Health Records.

All information is Confidential.

Patient Consent Form for Collection, Use, and Disclosure of Personal Information
Privacy of your personal information is an essential part of our practice, while providing you with quality medical care. We understand the importance of protecting your personal information, and we are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information.

All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your data. All electronic forms and consent forms are viewed only by your chosen doctor and assisting nurses unless you have expressly signed a Release of Records to make these forms available to another Health Care Provider or family member. In-office forms are utilised by the staff of the centre and adhere to the appropriate use and protection of your information.

Our Privacy Policy outlines what we are doing to ensure that:
- Only necessary information is collected about you;
- We only share your information with your consent;
- Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols;
- Our privacy protocols comply with privacy legislation and standards
How our Clinic Collects, Uses and Discloses Patients’ Personal Information:

The clinic understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined how the clinic is uses and discloses your information.

The clinic will collect, use and disclose information about you for the following purposes:
- To assess your health concerns
- To provide health care
- To advise you of treatment options
- To establish and maintain contact with you
- To remind you of upcoming appointments
- To communicate with other treating healthcare providers involved in my care, unless I direct the clinic otherwise
- To obtain previous investigation results and correspondence from other clinicians I have consulted to optimise my care
- To allow us to efficiently follow-up for treatment, care and billing
- To complete claims for insurance purposes
- To invoice for goods and services
- To process credit card payments
- To collect unpaid accounts
- To comply with all regulatory and legal requirements including court orders, statutory requirements to advise authorities of child abuse and reporting diseases and individuals who may be an imminent threat to harm themselves or others
- To use for educational and research purposes (this includes case summaries, photographs, lab results and other pertinent medical information). Your identity will be protected at all times and if necessary, identifying information will be altered to protect your privacy in all the above instances
By signing this Patient Consent Form, you have agreed that you have given your consent to the collection, use and/or disclosure of your personal information as outlined above.
Patient Consent:
I have reviewed the above information that explains how the clinic will use my personal information and the steps that the clinic is taking to protect my information.

I agree that the clinic can collect, use and disclose personal information as set out above in the information about the clinic’s privacy policies.
Full Name*

First NameLast Name
Date*

DayMonthYear
Signature*

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Informed Consent
Please note that this form must be signed prior to your first appointment.

Your clinician may recommend that certain procedures are performed to assist clarification of a provisional diagnosis. These procedures may include skin prick testing, intradermal testing, patch testing and food or drug challenges.

All our procedures are performed to internationally recognized best practice and align with ASCIA protocols.

Skin prick testing is a valuable tool for assessing allergy and carries a low risk of adverse reactions. Common effects are mild discomfort, itch, redness, minor swelling and possible eczema flare. Rarely, a susceptible person may experience syncope (faint). If there is a history of fainting during procedures, please make your clinician aware. There is a less than 0.01% risk of anaphylaxis to skin prick testing. All our clinicians are highly trained and have the resources the manage a reaction.

If you have any concerns, please let us know.
Full Name *

First NameLast Name
Date

DayMonthYear
Signature of Patient or Guardian indicating that they have read and agree to Informed Consent*

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Communication Policy
We understand that Allergic and Immunological symptoms are complex and sometimes stressful. In order to best meet your needs, it is important that we outline our communication procedure and policy.

All patients are reminded via SMS text about their appointment times. If you are unwell or cannot make an appointment please ring our clinic to discuss and reschedule.

Direct Patient Questions are not answered on Text Message or Social Media Platforms for legal reasons

Enquiries can be logged with clinic reception and a message will be left for the relevant Doctor or Nurse. Alternatively you are welcome to email the Allergy Nurses - nurse@compass.clinic Please understand that a response will be generally given within 72 hours. Anything that is more urgent or concerning, please present to your GP or nearest emergency department. Your GP is also welcome to contact our doctors directly.

Complex questions and new concerns: It is most appropriate that any complicated matter be discussed in person or via phone or skype consultation with your Specialist/Nurse. Please contact reception to book or for enquiries.
I Understand the Communication Policy*

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Our relationship with you
Our team strives to deliver the best immunology and allergy care in Australia. Your health is our foremost priority.

To assist our clinic's ability to provide excellent care, we ask that you agree to follow our policies.

Please arrive on time, allowing for traffic, finding the right clinic location, and parking. We always endeavour to run our clinics on time. Please be aware the nature of our work means that emergencies may occasionally arise and cause an unexpected wait for you.

If you are unable to attend your appointment, please notify us as soon as possible. Late cancellations mean that we are unable to offer these appointments to others who are waiting many months to be seen. Cancellation fees may apply at the discretion of the clinician. Repeated failures to attend booked appointments may result in us declining further bookings.

We ask that you treat our staff with courtesy and patience. There will be no tolerance of abusive behaviour.

Due to the nature of the current Covid-19 pandemic, we may require you to wear a correctly placed mask, show your vaccination status and socially distance as necessary. These actions will be in accordance with the current Queensland Health directives.

Your condition and therapy may require ongoing monitoring to ensure your safety and treatment effectiveness. Please return for the review appointments as recommended by your treating clinician. We are unable to properly support your care if you have not visited for a lengthy period. Issuing of scripts, treatment schedules and action plans outside of consultations will be at the clinician's discretion and only for patients seen within the last 12 months, or less if clinically required.

Compass Immunology Clinics are private clinics that rely on fee-for-service payment to function. The details of consultation fees are provided in your confirmation email. Payment is required at the time of consultation. By accepting your appointment at Compass Immunology Clinic, you are acknowledging your agreement to complete payment.

If you do not wish to pay for private care, please advise your referring doctor so they may direct you to a public hospital.

Please understand that a positive therapeutic relationship is essential for us to deliver quality care. We may decide to decline further appointments with patients and their families if our therapeutic relationship has been damaged through negative behaviours. In that instance, we will direct you back to your GP with options for alternative care.
I understand the policies regarding my relationship with the clinic*

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Demographic Information
Patient's Name:*

First NameMiddle NameLast Name
Preferred name (if different to above)
Birth Date*

DayMonthYear
Sex assigned at birth*

FemaleMaleIntersexOther
Gender identity

FemaleMaleNon-binaryPrefer not to discloseOther
Medicare Number*
Reference number on Medicare card*
Medicare Card Expiry Date*
Pension number (if applicable)
DVA number (if applicable)
Mobile Phone Number*
Home Phone Number (optional)

Area CodePhone Number
Email*
example@example.com
PLEASE check the email address you enter is accurate
Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry
Parent / Guardian 1

if patient under 18 years old
Full Name

First NameLast Name
Date of birth

DayMonthYear
Date
Parent's Medicare Number
Reference number on Medicare card
Medicare Card Expiry Date
Mobile Phone number
Home Phone Number (optional)

Area CodePhone Number
E-mail
example@example.com
Parent / Guardian 2 (if applicable)
Full Name

First NameLast Name
Date of birth

DayMonthYear
Date
Mobile Phone number
Home Phone Number (optional)

Area CodePhone Number
E-mail
example@example.com
Next of Kin: If different to above

First NameLast Name
Next of Kin Contact Number:

Area CodePhone Number
Relation to the Patient:
Emergency Contact Name:*

First NameLast Name
Relation to the Patient:*
Emergency Contact Number:

Area CodePhone Number
Emergency Contact Number*

Your health
How are you hoping we can assist you?*
More detail helps us find the right clinician for you and triage your appointment
Past medical history
Current medications
Any known allergies

Your visit

Please arrive on time, allowing for traffic and parking. Ensure you have checked the right location for your appointment as we have several clinic sites.
My referral was sent from:
Please upload your referral

Browse Files

Cancelof
Usual GP involved in your care:*
Name of GP
Details of your GP's clinic*
Name or location of GP clinic
Any other involved Health Care Providers (e.g. GP, Paediatrician, Dietitian):
Please ensure we know the details of your GP
Have you undergone any tests or investigations that are of relevance to your appointment?
Please provide details and where undergone
How Did You Find Out About Us?

Referred by GPReferred by other medical practitionerFriendFamilyWebsiteFacebookRecommendation by support groupOther - provide details below
Do you have any concerns or queries about your visit?

Thank You
We are grateful for your time in completing this form.

We look forward to meeting you and assisting your health.
Should be Empty:

Compass Immunology Clinic

Patient Consent Form for Collection, Use, and Disclosure of Personal Information

Informed Consent

Communication Policy

Our relationship with you

Demographic Information

Your health

Your visit

Thank You