ADHD DOCTORS TASMANIA

Email*

example@example.com

Mobile Number*

Who is your regular GP or regular GP practice? Please note that a condition of being a patient at ADHD Doctors Tasmania is open communication with your regular and previous GPs in writing and by phone.*

Please make sure the name written is exactly as shown on your Medicare card.

DATE OF BIRTH*

Date

Title*

Name*

Given NameSurname

Preferred Name

Occupation

Gender*

MaleFemaleOther

Ethnicity*

AUSTRALIAN, NON INDIGENOUSABORIGINAL BUT NOT TORRES STRAIT ISLANDERTORRES STRAIT ISLANDER BUT NOT ABORIGINALBOTH ABORIGINAL AND TORRES STRAIT ISLANDEROther

Address*

Street Address Line 2

Suburb

Post code*

Medicare Card Number*

Medicare Card Ref No*

MEDICARE CARD EXPIRY DATE eg. 10/25*

NEXT OF KIN name*

Given NameSurname

NEXT OF KIN phone number*

NEXT OF KIN relationship to you*

Do you smoke?*

YesNoEx Smoker

Do you drink alcohol?*

YesNo

Do you have any allergies*

YesNo

PLEASE SPECIFY ALLERGIES

PLEASE SPECIFY ALL PAST MEDICAL HISTORY - including any admissions to hospital in the last 5 years - please note that being a patient at ADHD Doctors Tasmania will require a thorough medical history to be collected from current and previous GPs, pathology centres, imaging locations, pharmacists, My Health Record and hospital records from all states of Australia.*

PLEASE SPECIFY ALL CURRENT MEDICATIONS*

PLEASE SPECIFY ALL RELEVANT FAMILY HISTORY INCLUDING CONDITION(S) AND WHO*

OUR PRIVACY AND MEDICAL INFORMATION

Complying with The Privacy Act, your consent is required for information collected. This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly access, diagnose, treat and be proactive in your health care needs. This means that we will use the information for administrative purposes, billing, disclosure to others involved in your health care; including specialists and other treating doctors outside this practice and disclosure to other doctors in the practice including locums to assist in your medical care. This practice may occasionally be involved in research and quality assurance activities to improve individual and community health care and practice management, in which your consultation may include the presence of a medical student or GP registrar. All information is de-identified. If you wish to opt out of any research undertaken by the clinic - please inform your doctor. We always wish to assure you that your health information is treated with utmost confidentiality. In accordance with medical legislations, except our GP doctors, our staff are not authorized to discuss or provide any test results to you. Under circumstances with a doctor's instruction, staff can provide a copy of results as per your communication preferences. Withouta consultation /phone consultation or your verbal/ written consent, doctors will not discuss or provide any test results. Your personal information is kept as an electronical record in the practice secured software system for identification purpose only. The paper containing of your personal information will be shredded and disposed at end of the day.

OUR COMMUNICATION

By signing this form, you acknowledge that appointment reminders, follow-up reminders and report recalls will be communicated via SMS. This is a courtesy service that we offer, it may not be sent on all occasions, and you havethe responsibility for making, attending, or cancelling appointments for your recall results. You reserve the right to opt out the SMS service at any time, however, you may not be contacted for recalling the results if your phone number provided is not contactable. You are acknowledged that the risk if you request the results to be send by the email you provided.

YOUR RESPONSIBILITIES

Patients are required to return for a consultation to obtain test results. If any results are abnormal and/or require urgent attention, we will contact you. Please make sure ADHD Doctors Tasmania has your current phone number and address details when booking or settling your account. It is crucial that you understand that this is your responsibility to ensure you contact and return for your results.

ALLIED HEALTH TEAM CARE ARRANGEMENT

If a patient has a chronic medical condition, they may be eligible for services under a General Practitioner Management Plan (GPMP) or Team Care Arrangement (TCA The GP Management Plans and Team Care Arrangements provides you with rebates for accessing allied health team services up to 5 times per calendar year. (Including chiropractor, dietician, podiatrist, and physiotherapy etc).

Similarly, a Mental Health Care Plan (MHCP) provides you with rebates for accessing psychologist services up to 10 times per year. However, it is your responsibility to be aware whether you have exceeded the total number of Medicare rebateable health services available in one calendar year under a GPMP or MHCP.

ZERO TOLERANCE POLICY

We have a zero tolerance policy for physical violence, racial, verbal or online abuse towards to our staff. Violation of Zero Tolerance Policy may lead to a police officer attendance. How did you hear about our practice?

Please tick only if you do not want your health summary shared / upload to MyHealth Record services. if you do not want to participate, you need to contact My Health Record Help line: 1800 723 471.

MY HEALTH RECORD

TICK IF YOU DO NOTWANT YOUR HEALTH SUMMARY SHARED / UPLOADED TO MYHEALTH RECORD SERVICES note: if you do not want to participate at all, you need to contact My Health Record Help line: 1800 723 471

How did you hear about our practice

By signing this form, you are agreed that that any fees are payable before any consultation. Any unpaid outstanding funds will lead to termination of our services. Under Australian legislation, service providers including GPs and allied health providers have rights to terminate the therapeutic relationship under circumstances including breach of our clinic policy or healthy relationship between you and the provider. I am aware and willing to pay the fee involved if my Medicare GPMP/TC or Mental Health Care Plan services exceed the limit per calendar year Non-Attendance Policy applies: Non-Attendance without a valid reason or prior notice will incur $50 fee. Investigations/specialists fees: all fees outside our practice are not within our scope, please double check fees prior to investigations/ specialist appointments. By completing the field above, I understand and agree to all the conditions for the service provided by ADHD Doctors Tasmania

TYPE YOUR NAME AND SIGN BELOW*

SIGNATURE OF PATIENT / GUARDIAN*

DATE FORM SIGNED*

Date

ADHD DOCTORS TASMANIA

NEW PATIENT REGISTRATION FORM