Prefix
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Mr
Mrs
Ms
Miss
Dr
Surname:
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Given Names:
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Preferred Name:
Date of Birth
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/
Day
/
Month
Year
Date
Email
*
example@example.com
Occupation
Address:
*
Address
City
State
Post Code
Mobile Phone:
Home Phone:
Referring Doctor
*
Clinic
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GP (If different)
Clinic
Medicare Number
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Ref Number
*
Expiry
Pension/Health Care Card
*
Yes
No
Pension/Health Care Card Number
Expiry
Private Insurance
*
Yes
No
Fund Name (if yes):
Membership Number
Veterans Affairs Card
*
Yes
No
Veterans Affairs Number (if yes):
Type of card
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Gold
White
Emergency Contacts
Next of Kin:
Full name
Relationship:
Contact Number:
Emergency Contact (if different to NOK):
Full name
Relationship:
Contact Number:
The information is for the primary purpose of providing quality health care. We need you to provide us with your personal details and full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in the following ways:Administrative purposes in running our medical practiceBilling purposes including compliance with Medicare and HIC requirementsDisclosure to others involved in your health care including treating doctors and specialists outside this medical practice.This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referral.: Please tick each box once read before signing
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1) I have read the information above and understand the reasons why information must be collected. I understand that I am not obliged to provide any information, but that my failure to do say may compromise the quality of the health care given to me. I am aware of my right to access the information collected about me, except in some circumstances where access may legitimately be withheld. I understand I will be given an explanation in these circumstances. I understand that if my information is to be used for any other purpose than set out above, subject to any limitations on access or disclosure that I notify this practice of, I consent to the retrieval of medical information, including reports and results from medical tests from others involved in my health care, including treating doctors, specialists, hospitals and health care professionals.
2) I have been provided with information regarding Dr Amanuel Tesfai's fees and understand that I am responsible for payment of these fees on the date of service. I understand that fees may change without notice.
3) Although it is not necessary to have a current referral to see the doctor, I understand that to obtain a Medicare rebate it is my responsibility to ensure I maintain a current referral for each appointment. I understand that a referral from a GP lasts 12-months and from a specialist lasts 3-months.
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