Patient Registration Form

Title

Surname

Given Name/s

Preferred name

Date of Birth

Gender

Ethnicity

How did you hear about our practice?

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mobile Number

Please enter a valid phone number.

Home Phone number

Please enter a valid phone number.

Work Phone Number

Please enter a valid phone number.

Preferred method of contact?

MobileHome phoneWork phone

Email address

Consent to SMS?

YESNO

Medicare Number

Medicare Reference (your number on card)

Medicare Expiry

Do you have Private Health Insurance - Hospital Cover?

Private Health Fund Name

Private Health Fund - Membership Number

Occupation

Concession Card

DVAHealth care cardPension

Concession Card number

Concession Card expiry

Overseas Student Health Cover - Fund Name

Overseas Student Health Cover - Membership Number

Payer of account (under 16 years to be link to parent on Medicare card)

Parent/Guardian Full Name

Parent Date of Birth

Date

Parent Medicare Number

Parent Medicare Reference Number

Parent Medicare expiry date

Next of Kin - Full Name

Next of Kin contact phone number

Relationship to patient

Emergency Contact Name ( if different to Next of Kin)

Emergency Contact - phone number

Referring Doctor

Usual GP

Please list past surgeries/operations and the year they were performed.

Medical Conditions

	Yes	No	Details if applicable
Asthma
Diabetes
Epilepsy
Blood Pressure
Heart Problems
Bleeding Disorders
Cancers
Gut disorders eg reflux
Mental Health Problems
Do you have a lap band?

Family History

	Yes	No	Details if applicable
Congenital abnormalities
Cancers
Inherited disorders
Blood Pressure
Heart Problems
Bleeding disorders
Other
Family History Unknown

Please list any prescription medications you are currently taking

Please list any Over-the-counter/Natural remedies you are currently taking

Please list any Allergies

Other

	No	Yes
Pap Smear/CST up to date?
Previous treatment for abnormal smears?

Our practice values the privacy and security of your personal health information and uses standards-compliant secure messaging. As a patient of our medical practice, we require you to provide us with your personal details and a full medical history, so that we may properly assess, diagnose and treat illnesses and medical conditions to ensure we are proactive in your healthcare. To enable ongoing care, and in keeping with the privacy act 1988, and Australian privacy principles, our aim is to provide you with sufficient information about how Your personal information may be used or just closed and record your consent or restrictions to this consent.

Your personal information will only be used for the purposes for which it was collected, or as otherwise permitted by law, and we respect your right to determine how your information is used or disclosed.

By signing below, you (as a patient/parent/guardian) are consenting to the collection of your personal information, and that it may be used to describe close by the practice for the following purposes:

1. Administrative purposes in running our practice.
2. Billing purposes, including compliance with Medicare requirements.
3. Follow-up calls, appointment reminder/recall notices via SMS, letter, or email for treatment, result, actions, and preventative healthcare.
4. Disclosure to others involved in your healthcare, including treating doctors and specialist outside this medical practice. This may occur through the referral to other doctors, or for medical tests, and in the reports or results return to us following the referrals.
5. Accreditation and quality assurance activities to improve individual and community health care and practice management.
6. For legal related disclosure, as required by a court of law.
7. For the purposes of research, only where de-identified information is used.
8. To our medical students and staff to participate a medical training/teaching, using only de-identified information.
9. To comply with any legislative or regulatory requirements eg. notifiable diseases.
10. For use when seeking treatment by other doctors in this practice.
11. Ad hoc newsletters my email for the purpose of sharing generic health related information.

At all times, we are required to ensure your details are treated with the upmost confidentiality. Your records are very important, and we will take all the steps necessary to ensure they remain confidential. Please complete the form below if you understand and agree to the following statement in relation to use, collection, privacy disclosure of your patient information.

Our doctors and staff collect information from patients primarily to provide proper care and treatment. We have a legal and ethical duty to protect patient information. Patient information may have to be disclosed to other doctors, nurses, therapists, and medical technicians so that health care is not compromised.

The doctor in this practice is a member of various medical and professional bodies. These organisations provide valuable services to their members. They require their members to provide information in relation to their medical practice, which may include patient information.

I give permission for my personal information to be collected, used and disclosed as described above, including follow-up phone calls.

I understand only my relevant, personal information will be provided to allow the above actions to be undertaken, and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing. I understand that I can access the full privacy policy for further information.

I am aware that the practice policy requires all patients to see your doctor for test results, and whilst every effort will be made to contact patients with abnormal results, it cannot be assumed that test results are normal if there is no contact from our clinic.

I agree to pay all fees associated with my care at the time of consult.

Transfer of health information: you may have consistently consulted with a GP at another practice. The health information held by that GP may assist us with your future healthcare needs. You may wish to have a copy or a summary of your health records transferred to this practice. Please ask the receptionist for more information about how how this can take place

I have read the information above, and understand the reasons why my information must be collected, and the purposes for which my information maybe used or disclosed by Ritu Rana Medical . I understand that if my information needs to be used for any purpose, other than that set out above, my further consent will be obtained.

Signature

Date

Ritu Rana Medical will regularly send emails with attached documents (such as certificates, letters, appointment details, care, and treatment requests/request forms, procedural information, and quotes) that have not been encrypted with a password. Do you consent to Ritu Rana Medical sending an email with attached documents to your nominated email, GP practice, and any corresponding treating doctors?

YESNO

Ritu Rana Medical will send sms to your nominated mobile number. Information may include appointment reminders, urgent messages or unanswered calls messages. Do you consent to Ritu Rana Medical smsing you details regarding appointments and information regarding care and treatment?

YESNO

Name

First NameLast Name

Signature

Date

What is Ultrasound?

Ultrasound uses sound waves to produce images. The sound waves are transmitted into your body from a small handpiece that is called an ultrasound probe. Some of these waves are reflected and are processed by the ultrasound machine to form pictures that are shown on a TV screen and recorded.

Is Ultrasound Safe?

Ultrasound has been around for about 60 years now and numerous studies on patients and children, who had been examined before birth, have shown that it is a safe technique with no harmful side effects.

The trans-vaginal ultrasound procedure

The standard technique for looking at the female pelvis, especially before and during IVF or other fertility treatment cycles is by performing an internal trans-vaginal scan. The procedure will only take about 2 minutes. With your consent, asked to remove the bottom half of your clothing and lie down on a couch with a sheet covering you. You will be treated with dignity and your privacy always protected. The Doctor or Nurse will explain in detail what is involved and why it is important to have this scan done this way and how it gives clearer images. The examination will be performed by a Doctor.

This procedure involves a sterilised probe with some gel-like lubricant covered by a protective sheath being inserted into the vagina and manipulated very gently to show the anatomy of the pelvis. This probe is usually inserted by the examiner. This allows transmission of the sound waves into your body to allow a close look at your pelvic organs such as the uterus and the ovaries.

Results

Your scan will be read by the treating clinician and the results discussed with you. The Clinician will use this information to determine the next stage of your treatment.

Patient Registration Form

Personal Medical Information

Patient Privacy in our Practice

Sharing of Information Consent

Pelvic Ultrasound Patient Information