New Patient Form

Welcome to the Bayside Heart.

Important: This patient form is for patients that have an existing appointment.

If you do not have an appointment with us yet, please call us directly.

New Patient Information

Title

Surname

Given name

Preferred name

Date of Birth

day

month

year

Sex

Male

Female

Others

Address

Street Address City Postal / Zip Code

Home phone

Mobile Phone

Occupation

Medicare Number

Reference Number

Expiry Date

Department of Veterans' Affairs

Number

Expiry Date

Health Fund Name

Health Fund Membership Number

Full Name

Phone

Relationship

Regular GP

Clinic Name

Patient Consent

We ask you to provide us with your personal details and full medical details so that we can assess, diagnose, treat and provide you with the best possible health care we can. The information you have provided will be used in the following ways:

Administrative purposes in running our medical practice
Billing purposes, including compliance with Medicare & Health Insurance 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 results returned to us following the referral.
I have read the above information and understand the reasons why information must be collected. I am aware that if I do not have to supply the information requested of me, however my failure to do so may compromise the quality of the health care andtreatment given to me.

I am aware of my right to access the information collected about myself, except in circumstances where access may legitimatelybe withheld. I understand I will be given an explanation in these circumstances.

I understand that if my information was to be used for any other purpose than set out above, my consent will be obtained.
I consent to the handling of my information by this practice for any purposes set out above. I consent to the retrieval of medicalinformation, including reports and results from medical tests from others involved in my care, including treating doctors,specialists, hospitals, health care professionals and facilities outside this practice.

Attach your GP Referral

Signature

Date