Patient Information - Adelaide & Hills ENT

Patient Information Form

Are Account Holder details the same as patient details?YesNo

If NO please fill in who is responsible for the payment of the account

If a child under 18 years, is there any- Parenting AgreementsCourt OrdersUnder DCP

Prefix

Gender

Surname

Given Name(s)

Date of Birth

Relationship to Patient

Account Holder / Parent Medicare number

Number on Medicare card

Please Advise Staff If This Appointment is Related to A Workcover Or Third-Party Claim

Patient Details

Prefix

Gender listed with Medicare

Surname

Given Name(s)

Date of Birth

Age

Occupation

Address

Suburb

Postcode

Postal Address (if different from above)

Home Ph

Work Ph

Mobile

Do You Consent To Receiving SMS Reminders And Emails Relating To Your AppointmentsYesNo

Email Address

Patient Medicare Number

Number On Medicare Card

DVA (Dept Veterans' Affairs) Number

Card ColourGoldWhite

Please State Condition Covered By White Card

Do You Have Private Health Insurance?

Hospital Cover

Extras Only

Health Fund

Membership Number

Insurance Held For Longer Than 12 Months?YesNo

Emergency Contact

Name

Contact Number

Relationship

Medical History

Allergies

Previous Ear, Nose, Throat Or Voice Surgery

General Practitioner Name

Clinic Address

Privacy Statement and Consent Form

This practice provides high quality continuing care for you. In compliance with the privacy legislation and consistent with maintaining confidentiality and trust with your doctor, this practice wishes to inform you:

Information collected and disclosed about you requires your consent;
Why, how and who we disclose this information to can be for any of the following purposes:
Diagnosis and treatment of your problem including practice staff, specialists and other healthcare providers involved in your care
Billing and collection of professional fees
Agents that you have given authority and consent to release information to
Accreditation and quality assurance purposes
Teaching and research

You can discuss any concerns you may have about how we handle your information with our staff.

I, (full name)

Or as the legal parent / guardian of(child’s full name)

consent to Adelaide & Hills ENT collecting my personal information.

Consent to Adelaide & Hills ENT providing me with medical correspondence and other confidential information as necessary in relation to medical documents and information associated with my care via email to the email address stated overleaf.

Adelaide & Hills ENT will use the nominated address and I acknowledge that it is my responsibility to ensure the nominated email address is secure and confidential.
There is no guarantee that an email sent to us or by us will be secure, virus fee or successfully delivered.
I acknowledge and accept that Adelaide & Hills ENT is not liable if, due to circumstances beyond its control, messages sent to the nominated address are intercepted, delayed, corrupted or received by someone else.

I understand that the purpose of the collection of this information is required to provide continuing medical services to me. I understand that the information collected may be used for the purposes of continuing care and may be disclosed to other health care providers or organisations.

Signature

Date