Patient Consent

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. In keeping with the Privacy Act 1988 and Australian Privacy Principles, your information may be used or disclosed as follows:

■ Administrative purposes in the operation of our practice.

■ Billing purposes, including Medicare compliance.

■ Follow-up reminders/recalls (including SMS).

■ Disclosure to other healthcare providers (referrals, results).

■ Accreditation and quality assurance activities.

■ Legal disclosure as required by a court of law.

■ Research purposes (de-identified only).

■ Teaching/training of staff (de-identified only).

■ Compliance with legislative/regulatory requirements.

■ For treatment by other doctors in this practice.

Personal information

Title *

MrMrsMissMs

Gender (identify as) *

MaleFemale

First Name *

Last Name *

Date of Birth *

Contact Number *

Email *

Email Address

Address *

Street address *

Suburb *

State *

Post code *

Do you have a Medicare card? *

YesNo

Medicare Card Number *Please note: this section requires your Medicare card number entered with no spaces and 10 digits

Medicare card Expiry Date *

IRN (Number next to your name on medicare card) *

Please enter your IHI number *IHI can be obtained by visiting https://www.servicesaustralia.gov.au/how-to-get-individual-healthcare-identifier?context=22591

Do you have a government concession card? *

Yes No

Emergency Contact - Next of Kin

First Name *

Last Name *

Contact Number *

Relationship to you *

Cultural Identity

To assist with health initiatives, are you Aboriginal and/or Torres Strait Islander? *

NoYes - AboriginalYes - Torres Strait Islander Yes - Both

Do you identify as someone from a culturally or linguistically diverse background?

NoYes

Please elaborate:

Do you require an interpreter service? *

No Yes

Your Health Information

Do you have any allergies? *

NoYes

Please list your allergies *

Current Medications (including over the counter medications, vitamins and minerals *

Surgery Details *

Please list other medical history *

Lifestyle Risk Factors

Smoking *

NoCeasedYes

When did you stop smoking? *

How many per day do you smoke? *

Do you drink alcohol? *

YesNo

How often do you drink alcohol? *

Recreational Drug Use *

NoYes

Please list type of drug use and frequency *

Please enter the type of cancer *

Please enter other significant condition *

Practice Policies and Consent

I am aware that all consults require full pre payment to secure a booking. If no payment has been made prior to your appointment you consultation will not go ahead.
I agree to attend regular follow-up consultations in the clinic or via Tele-health as directed by my Practitioner and at least twice a year in person and face to face with the treating doctor for continuity of care.
I understand that I am not eligible for a refund if I provide false or misleading information in this consent form.
I understand that New Wave Clinic has a Zero Tolerance policy for abusive and/or threatening behaviour towards Staff and Doctors. Breaches of this policy will not be tolerated and will result in you being asked to find another practice and will be deemed ineligible for a refund.
I understand my participation is voluntary
I understand I have the right to withdraw my consent and cease consultations at any stage
I understand my referring doctor and/or healthcare team may be contacted in reference to my treatments
I understand my consent relates to a period of care which may involve several consultations via telehealth or face to face
I understand New Wave Clinic is a private billing practice that do not offer medicare rebates for consultations
I understand that if I become unwell I will call 000

What information do we collect about you?

New Wave Clinic, our doctors and staff collect information from patients primarily to provide the best quality and continuity of care. This may include other medical specialists, nurses, pathologists, healthcare providers and health administrations services so that your health care is not compromised. We require 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. This includes your name, contact details and Medicare details. All personal information in relation to your visit is kept safely and securely within the practice.

Why and how do we collect this data?

We are required to obtain your consent to collect personal information about you. The information we collect about you helps us to keep up to date details about your needs, so we can care for you in the best possible way. We also use the information to better manage and plan this service. We will collect this information directly through you and will use the information you provide in the following ways:Administrative purposes in running our medical practice Billing PurposesDisclosure to others involved in your healthcare, including treating doctors and specialist outside the medical practice. This may occur through referral to other doctors, or for medical test and in reports of results returned to us through the referrals. Disclosure for research and quality assurance activities to improve individual and community health care and practice managementEmergency situations whereby medical officers/ hospitals require access to patients notes for treatment purposes.

How can my personal information be accessed?

If you have changes to your personal information or wish to review your personal information, please ask one of our friendly staff.

Patient Privacy Consent

I have read the information above and understand the reasons why my information must be collected. I am aware that New Wave Clinic has a privacy policy on handling patient information. I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me. I am aware of my right to access the information by this practice for the purposes set out above, subject to any limitations on access or disclosures that I notify this practice of.

Consent

I agree that by signing this form I acknowledge that I have reviewed and confirm my consent to the requirements outlined in this form and that the information that I have provided is correct to the best of my knowledge.

Full name *

Date *

Your signature *

Draw signature|Type signatureClear

Please note: When submitting this form if you are seeing the consent form questions still, this means your consent form has not submitted. Please check all questions have been answered and that your medicare card number section has 10 digits and no spaces.