Your Personal Information ---MrMrsMsMissMstrDrRevSr DOB*: How did you hear about us?* ---Word of mouthWebsiteSignageSocial MediaOther Your Medical Information Do you have any allergies or are you sensitive to drugs or dressings?NOYES Do you smoke? NOYES If yes, how many cigarettes per day? Do you drink alcohol? NOYES If yes, how many glasses per day? Height*: (cm) Waist*: (cm) Weight*: (kg) Do you take any type of drug? NOYES Do you have an ADVANCED HEALTH DIRECTIVE? NOYES Do you identify as someone from a culturally and/or linguistically diverse background? NOYES To assist with health initiatives, are you Aboriginal or Torres Strait Islander? NOYES Your Healthcare Information DVA Card type: WhiteGold Our practice uses a reminder system to maintain your health record. The practice sends reminders and recalls via SMS, POST and TELEPHONE. By becoming a patient of this practice you are automatically consenting to the above mentioned procedure. Emergency Contact and Next of Kin Do you have any previous illness or medical condition we need to be aware of (tick below)? High blood pressureBleeding tendencyHepatitisDeep vein thrombosisHeart valve surgery AnginaStomach UlcerSkin cancer surgeryCurrently pregnantDiabetes AsthmaVaricose VeinsHIVOther Your Health Information To enable ongoing care and total quality improvement within this practice and in keeping with the Privacy Act (1988) and the National Privacy Principles, we wish to provide you with sufficient information on how your personal health information may be used or disclosed and record your consent or restrictions to this consent. Your personal health information will only be used for the purposes for which it was collected, or as otherwise permitted by law and we respect your right to determine how your personal health information is used or disclosed. The information we collected may be collected by a number of different methods and examples may include: medical test results, notes form consultations, Medicare and health insurance details, data collected from observations and conversations with you, and details obtained from other health care providers (e.g. specialist correspondence). By filling out this form, you (as a patient/guardian) are consenting, that on obtaining your personal health information it may be used or disclosed by the practice for the following purposes: * follow up reminder/recall notices for treatment and preventive healthcare; * for accounting procedures and the collection of professional fees; * the diagnosis and treatment of any health condition, including the communication of relevant information only, to practice staff, specialists and other healthcare providers to ensure quality care is provided; * Accreditation and Quality Assurance activities are conducted by professionally trained non-treating GPs and other professionally trained and qualified persons, e.g. General Practice Managers; * For legal related disclosures as required by Court of Law; * For the purposes of research where de-identified information is used; * To allow medical students and staff to participate in medical training/teaching using only de-identified information; * For disease notification as required by law; * For use when seeking treatment by other doctors in this practice. * For third party consent to obtain results of pathology/imaging/x-rays/specialist letters on your behalf, if yes please write the name & DOB of the third party: DOB: At all times, we are required to ensure your details are treated with the utmost confidentiality. Your records are very important and we will take all steps necessary to ensure they remain confidential. I give my permission for my personal health information to be collected, used and disclosed above. I understand only my relevant personal health information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter to restrict my consent at any time by notifying this practice in writing. I agree to assign my right to benefits to the provider who rendered the services.