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New Patient Intake

Legal Full Name

Preferred name

Date of Birth

Gender Identity

Gender Identity

Do you need an interpreter?

Do you need an interpreter?

Contact Details

Mobile phone

Email address

Home address

Healthcare Identifiers

Medicare card number

Pension or Healthcare card number

Workcover claim number

Workcover Case Manager Name

DVA Card Number

DVA Card type

DVA Accepted Conditions (if White card)

Next of Kin

Name

Contact Number

Medical Records

Do you give consent for us to share your medical records with other healthcare providers or legal professionals when it is necessary for your care or treatment?

Do you give consent for us to share your medical records with other healthcare providers or legal professionals when it is necessary for your care or treatment?
A
B

Referral and other relevant reports

Please upload your GP referral and any other relevant documents e.g. scan reports you wish Dr Lucas to review prior to your appointment. If you have multiple documents you may alternatively email them to reception@synosia.com.au

If you have previous radiography but do not hold copies of reports, please state below where the scans were completed, and we will endeavour to access them prior to your appointment.

GP/ Referrer Details

Name of referring GP/ Specialist

Name of Referring Practice

Phone

Patient Consent

Please read this consent form carefully prior to signing.

This practice values privacy and security of your personal information. We require you to provide us with your personal details and relevant medical history so we may properly assess, diagnose and treat illnesses and medical conditions, ensuring we are proactive in your health care.

To enable ongoing care, and in keeping with the Privacy Act 1988 and Australian Privacy Principles,our aim is to provide you with sufficient information on how your personal information may be usedor disclosed and record your consent or restrictions to this consent.

Your personal information will only be used for the purposes for which it was collected or asotherwise permitted by law, and we respect your right to determine how your information is used or disclosed.

By signing below, you (as a patient/parent/guardian) are consenting to the collection of your personal information, and that it may be used or disclosed by the practice for the following purposes:

- Administrative purposes in the operation of our general practice.

- Billing purposes, including compliance with Medicare requirements.

- Follow-up reminder/recall notices for treatment and preventative healthcare, frequently issued by SMS.

- 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 or results returned to us following the referrals.

- Accreditation and quality assurance activities to improve individual and community health care and practice management.

- For legal related disclosure as required by a court of law.

- For the purposes of research only where de-identified information is used.

- To allow medical students and staff to participate in medical training/teaching using only de- identified information. To comply with any legislative or regulatory requirements, e.g. notifiable diseases.

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. Please complete the form below if you understand and agree to the following statements in relation to our use, collection, privacy and disclosure of your patient information.

I have read the information contained within in the patient

consent and understand the reasons why my information must be collected, and the purposes for which my information may be used or disclosed. I understand that if my information is to be used for any purpose other than that set out above, my further consent will be obtained.

I give permission for my personal information to be collected, used and disclosed as described above, including contact via SMS to my mobile phone number. I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.

Patient name

Patient signature

Signature