ACT Lung and Sleep New Patient Form

ACT Lung and Sleep

Specialist in Respiratory and Sleep Medicine
New Patient Form
Name*

PrefixFirst NameLast Name
Date of Birth*

DayMonthYear
Gender *
AboriginalTorres Strait IslanderNone of aboveOther
Mobile Number*
Please enter a valid phone number.Format: 0000 000 000.
Home / Alternate Number

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Postal Code
Emergency Contact*

Full NameBest Contact Number
Medicare*

Medicare NumberReference on Card
Expiry Date

DayMonthYear
Pension Concession Number
Expiry Date

DayMonthYear
Private Health Fund

Name of ProviderMembership Number
Name on CardReference on Card
GP*

Name of GPName of Practice
YesNo - please provider details
Referring Doctor

Name of DoctorName of Practice
YesNoOther
Medical History
Patient's Consent

1. The privacy and security of your personal information is important to ACT Lung and Sleep, and is protected by law (The Privacy Act 1988). Our practice will work closely with other professionals and healthcare providers to coordinate the best support for you. This means your informed consent for the sharing of information will be sought and respected in all situations unless:
- we are obliged by law to disclose your information regardless of consent or otherwise;
- it is unreasonable or impracticable to gain consent or consent has been refused; and
- the disclosure is reasonably necessary to prevent or lessen a serious threat to the life, health or safety of a person or group of people.
2. ACT Lung and Sleep reserves the right to charge a fee of $100 for any scheduled appointments that are:
- cancelled with less than 48 hours notice
- missed without calling to cancel (no show)
I am aware of my rights to access to my personal information.I am aware of my rights to withdraw my consent at any time.I understand that my provider must comply with relevant privacy laws and I will contact the organization immediately if I feel that these laws have been breached.I understand why certain information about me may need to be provided to other service providers in order to coordinate the best support for me.I agree about the cancellation fee under the above circumstances.
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Date*

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ACT Lung and Sleep

New Patient Form

Patient's Consent