Pulse Holistic Medical centre new patient form created in March24

Title

First

Middle

Surname

Gender Male/Femal/other

Date of Birth

Date

Country of Birth

Do you identify as being Aboriginal and/or Torres Strait Islander

Mobile Phone

Home phone number

Work phone number

Email

Language

If English is not your first language, do you require an interpreter?

Address

How would you prefer to be contacted

Medicare Number

Ref ( the number in front of your name)

Medicare Expiry date

Concession (Pension/Health care) Card Number

Expiry date

DVA Card if you have one

DVA card Expiry

Occupation

Next of Kin

Relationship

next of kin phone

Emergency Contact

Relationship

Emergency phone number

Your Health Information

Allergies - Do you have any allergies or are you sensitive to drugs or dressings?

If say YES, Please list your allergies

What is your body Mass Index(BMI)?

Weight

Height

Waist

What is your Blood Type

Do you have a Power of Attorney in Place

Do you have an Advance Health Directive in place

Are all childhood immunisations up to date?

Smoking

Alcohol

Family Health History Information

Have you or any members of your family been diagnosed with:

Heart Disease: Family Member

Asthma: Family Member

Diabetes: Family Member

Hypertension high blood pressure: Family Member

Depression: Family Member

Cancer-type: Family Member

Other significant conditions provide details

Privacy Act

We value your privacy. All information about you, held in this practice, is kept in the strictest confidence. With the introduction of the Privacy Act Amendment (2000) in December 2001 we remain committed to protecting your privacy and are now asking for your express consent for the use and disclosure of your personal health information in the course of your health care. This consent allows those involved in your health care access to the information necessary to continue the high standard of health service you have come to expect of us.

This information is also for billing purposes, including compliance with Medicare and Health Insurance Commission requirements. We cannot do referrals, scripts or order investigations that have your private details on it without this consent. Disclosure to other health care professionals involved in your health care may include other treating doctors and specialists outside this medical practice that we have referred you to, or who require information to complete your care. This includes Pathology, x-rays and other medical tests, pharmacies, hospitals, physiotherapists, podiatrists, psychologists, other doctors in this practice, nursing and reception staff.

Your file will never be released from this surgery without your signed consent i.e. other medical practices or insurance

Data Privacy

Our practice records and securely stores information about your health. We may use this information to take part in quality improvement and research to improve the quality of care provided to you and your family.

What happens to my information?

Be assured, the information collected, used and stored for these purposes remains anonymous to comply with the Australian Privacy Principles contained in the Privacy Act 1998. In the unlikely event of a breach of your data, you GP is obligated to notify you as soon as possible.

Can I opt out? Yes.

Talk to the practice manager or one of our receptionists. Once you opt out, your information will not be used for quality improvement or research purposes.

Email Policy

Emailing has become a pivotal source of communication in today's society. Pulse Holistic Medical Centre has introduced an email service to enable patients to receive results and correspondence from the practice only as directed by the Doctor via email.

This email service is limited to the following:

Letter of notification that the patient is due for a review or PAP smear.

Letter of notification that the patient is needing to be seen non-urgent regarding test results.

Patient results as per doctors' orders

Doctor notes or letters from doctor

Pathology/Imaging forms

Patient history

Please do not email for appointments or clinical information.

Emails are sent over the internet and as such may not be secure. Once your results are in your care, the surgery cannot take responsibility.

Practice Fees

General Practitioners

Initial consult $500 (1 hour) rebate $122.15

Second Consultation $370 (40mins-60mins) rebate $122.15

Prolong Consult $420 (over 1 hour) rebate $197.90

Extra Long Consultation $270-$400 (40mins-60mins) rebate $122.15

Long Consultation $185 (20mins-40mins) rebate $82.90

Standard Consultation $100 (up to 20mins) rebate $42.80

Brief Consultation $30 (less than 6mins) rebate $19.60

Non-Attendance admin fee $15(scripts / pathology request / referrals)

Please ask our reception for any other prices not listed above.

Danielle Roberts-Naturopath No rebate

Initial consultation $170 (1 Hour)

Follow up Consultation $150 (1 Hour)

Follow up Consultation $130 (3/4 Hour)

Follow up Consultation $100 (30 mins)

Gina Wilson-Naturopath No rebate

Initial consultation $170 (1 1/2 Hours)

Follow up Consultation $150 (1 Hour)

Follow up Consultation $130 (3/4 Hour)

Follow up Consultation $100 (30 mins)

CANCELLED/FAILURE TO ATTEND APPOINTMENTS

Due to the difficulty of filling last minute cancellations and high demand for appointments, we respectfully request 24-hour notice. If you fail to attend two (2) or more appointments, you will be charged a fee of $75.00 payable prior to booking your next appointment.

Personal Declaration, printed name

Signature

Date

Declaration on behalf of another person unable to comprehend or complete personal declaration Signed for and on behalf of the above patient.

Your name (signed for and on behalf of the above patient

Signature

Relationship to patient

DOB

Medicare Number

New Patient Registration Form

Pulser A

Pulse Holistic Medical Centre New Patient Registration Form