Title —Please choose an option—DrProfMrMrsMsMissMaster
Family Name (required)
First Name (required)
Middle Name
Preferred Name (required)
Date of Birth
Gender —Please choose an option—MaleFemale
Gender Identity (Optional)
Religion (Optional)
Occupation (Optional)
Street Address
Suburb
Post Code
Postal Address (If different from street address)
Contact Number
If Patient is under 18, please specify who's contact number was provided —Please choose an option—The PatientA Parent/GuardianA Friend/Family MemberOther
Secondary Number (Optional)
Email Address
Country of Birth
Cultural Identity —Please choose an option—Australian (Not Indigenous)AboriginalTorres Strait IslanderBoth Aboriginal and Torres Strait IslanderNot Provided
Next of Kin Name
Next of Kin Phone Number
Next of Kin Relationship
Emergency Contact Name
Emergency Contact Number
Emergency Contact Relationship
Medicare Number
IRN
Medicare Card Expiry Date
Select any concession card that you hold NonePension Card HolderHCC Card Holder
Pension/HCC Expiry Date If Applicable
Pension Entitlement Number If Applicable
Select any that apply NoneDVA Gold Card HolderDVA White Card Holder
DVA Card Entitlement Number If Applicable
I give consent to receive the following electronic reminders / messages: (Optional)
Appointment Reminders (Confirmation and reminders about appointments)
Clinical Reminders (Reminders about treatments or clinical updates)
Clinical Communications (Medical results & messages from practitioners)
Health Awareness (Digital leaflets & relevant alerts based on medical history)
By communication electronically with the Hinterland Medical Centre, I dismiss the practice from all claims, losses, expenses and liabilities caused by any problems in using electronic mail with the risk of interception by third parties and non-recipients.
I agree to the above electronic communications conditions (Required)
Welcome to the Hinterland Medical Centre. Please read this consent form carefully prior to signing. This general 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 assess, diagnose and treat illnesses and medical conditions, ensuring we are proactive in your health care. To enable ongoing care, and in keeping with the Privacy Act 1988 and Australian Privacy Principles, we wish to provide you with sufficient information on how your personal information may be used or disclosed 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. The information we collect may be collected by a number of different methods and examples may include: medical test results, notes from consultations, Medicare details, data collected from observations and conversations with you, and details obtained from other health care providers (e.g. specialist correspondence). By signing below, you (as a patient/parent/guardian) are consenting to the collection of your personal information, and that it may be used or disclosed by the practice for the following purposes: • Administrative purposes in running our general practice. • Billing purposes, including compliance with Medicare requirements. • Follow-up reminder/recall notices for treatment and preventative healthcare. This practice contacts patients via SMS appointment reminders and health reminders and this is one of the purposes for collection of mobile phone numbers. • Disclosure 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 referrals. • Accreditation and quality assurance activities to improve individual and community health care and practice management. • For legal related disclosure as required by a court of law. • For the purposes of research only where de-identified information is used. • To allow medical students and staff to participate in medical training/teaching using only de-identified information. • To comply with any legislative or regulatory requirements e.g. notifiable diseases. • For use when seeking treatment by other doctors in this practice.
At all times, we are required to ensure your details are treated with the utmost confidentiality. Your records are very important and we will take all steps necessary to ensure they remain confidential.
Please select the check box below if you understand and agree to the following statements in relation to our use, collection, privacy and disclosure of your patient information.
I have read, and agree to the above Patient Consent Form (Required)
