REFERRING DOCTOR

Who is your GP? *

Please list other Doctors who should receive correspondence about your visit.

PREFERENCE FOR APPOINTMENT DAY

PATIENT DETAILS

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender *

MaleFemaleOther

PATIENT CONTACT DETAILS

Home Phone

Mobile Phone *

Work Phone

Email

Address *

Postcode *

City / Suburb *

State *

MEDICAL HISTORY

Do you have any medical conditions that your doctor should be aware of (Allergies, Asthma, Diabetes, Heart conditions)? *

YesNo

If YES, please give details

EMERGENCY CONTACT / NEXT OF KIN DETAILS

Name *

Home Phone

Mobile Phone *

Email

Do you consent to us giving this person information regarding results and appointments? *

YesNo

PLEASE NOTE: In the event of a change in circumstances e.g. Relationship change, or some other change which may require a change of the nominated carer/family member authorised to receive patient information, it is THE PATIENTS' responsibility to immediately information the practice.

MEDICARE

Medicare Card No. *

Position on Card *

Expiry *

Medicare Details

If patient is under the age of 16 please supply the Medicare details of their guardian for rebate purposes.

Parent/Guardian Medicare Number

PRIVATE HEALTH INSURANCE

Provider

Membership No.

Expiry

Concession Card / DVA Card

Concession Card Number.

Expiry(mm/yyyy)

Card Type

HCCPension

Dept. Vets Affairs Number.

DIGITAL PHOTOGRAPHY - (You may change this authorisation at any time)

By Checking the below boxes, I UNDERSTAND and CONSENT to clinical photography for the following purposes:

CLINICAL - Monitory, Diagnosis and treatment of any skin or skin related issues. For example, to be recorded within my notes to form part of my permanent health record, or to be sent via secure web email system for a dermatologist to look at in order to help with my care (I will be identified for this purpose) *

YesNo

TRAINING - Teaching of health professionals (eg. doctors, nurses) by way of printed or electronic means (photos will be deidentified for this purpose) *

YesNo

RESEARCH - Research publication to increase health professional awareness and education of skin-related issues (eg. in medical journals, electronic publications or information booklets) (photos will be deidentified for this purpose) *

YesNo

GENERAL - General publication to increase patient awareness and education of skin-related issues (eg. leaflets or electronic publications) - photos will be deidentified for this purpose. *

YesNo

I understand that I am free to withdraw my consent to the above purpose at any time, although in the case of images used for teaching or publications, it may be impossible to totally remove these from public viewing.

I understand that refusal or withdrawing of consent to any of the above uses will have no effect on the medical care that I receive.

SIGNATURE

Shades Dermatology collects information from you for the primary purpose of providing quality health care. Federal Privacy Law requires your consent to this. We need your personal details and full medical history (which may include photographic records) so that we may properly assess, diagnose, treat and manage your health care needs. This means we will use the information you provide in the following ways:

Adminstrative purposes in running our medical practice, which may include confirmation of your appointment via SMS or email
Billing purposes - including, but not limited to, compliance with Medicare and the Health Insurance Commission requirements.
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 of results returned to us following the referrals.
Disclosure to other doctors in the practice, locums and trainees attached to the practice for the purpose of patient care and teaching.
Emergency situations whereby medical officers/hospitals may require access to patient notes for treatment purposes.

CONSENT

I understand for security purposes the common area at Shades Dermatology is under video surveillance.
I have read the above information and understand the reasons why my information must be collected.
I understand that I am not obliged to provide any information requested, but that 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 collected about me, except in some circumstances where access might legitimately be withheld and that an explanation will be given to me in this circumstance.
I understand that if my information is to be used for any purpose other than the above, Shades Dermatology will seek my consent prior.
I consent to Shades Dermatology using my personal information in the ways outlined above.
I understand that Consultations are not bulk billed &/or not payable by private health insurance, and fees are payable on the day of consultation.
I also understand that if there is a need for a procedure or treatment, there will be additional fee for these.
I also understand that an additional fee is required for a procedure or treatment occurring on the same day as an initial consultation.
I understand that by accepting an appointment at Shades Dermatology I agree to adhere to the Dermatologist's instructions and medical recommendations.
I understand that my results will be communicated from the treating Doctor via primary sms/ email contact provided and that a phone call from Shades Dermatology staff will follow to plan any associated treatment.
I understand I am responsible to call for my results if I have not had my results confirmed a week after my appointment.
I understand medical providers and staff of Shades Dermatology are required to obtain digital photography in relation to my health care.

I consent to these above terms. *

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

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