Riverina Endovascular

Surname

Given Name:

Second Name:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

DOB:

Telephone: Home:

Mobile:

Email:

Next of Kin :

Relationship:

Ph:

If we are unable to contact you by phone, do we have your permission to leave a message with a family member?

Yes
No

Do you consent to receive SMS reminders of your appointments with the practice?

Yes
No

Medicare No:

Ref No:

(this is the number next to your name)

Pension Card:

DVA card: Number:

Private Health Fund:

Member No:

Referring Doctor:

Usual GP :

Do you have any allergies?

Yes
No

If so, what?

MEDICAL HISTORY

Do you have a past medical history of any of the following? (please tick)

SOCIAL HISTORY

Smoking (Please tick):

Never smoked
Ex-smoker
Still smoking
How many?

Patient name (Please print)

CONSENT TO COLLECT PATIENT INFORMATION
This medical practice collects information from you for the primary purpose of providing quality health care. We requires you to provide us with your personal details and 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 practice.
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
Disclosure to others involved in your health care, including treating doctors and specialist outside this medical practice as advised by you.

I understand the reason why my information must be collected.
I understand that I am not obliged to provide any information requested 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 about me, except in some circumstances where access might 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 purpose other than the above, my consent will be sought.
I consent to the handling of my information by this practice for the purpose set out above, subject to any limitations on access or disclosure of which I may notify this practice.

I consent to clinical photographs to be taken for the purpose of monitoring, comparison and education purposes to aim my treatment.
I consent to receive SMS reminders of my appointments in the practice.

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Patient Information Form

Patient Information Sheet