Form cover
Page 1 of 1

New patient registration

Please note that all new patient appointments require a current referral dated within the last 12-months. This must be received by the clinic prior to your initial consultation. Please upload it below or email it to [email protected].

Contact details

Title

First Name

Last Name

Date of birth:

Home address:

Street

Suburb

Postcode

Postal address (if different to above):

Street

Suburb

Postcode

Mobile

Email

Emergency contact details:

Name

Relation

NOK Mobile

Medical details:

Medicare card no.

IRN (ref #)

Exp date (MM/YYYY)

Referring Doctor Name

GP Name (if different to above)

Referring Doctor Clinic

Payment

I am attending MRG as a...

Please provide further detail:

*note: if under Workcover or TAC, prior written approval is required.

Concession

Concession card CRN

Expiry MM/YYYY

Please select what applies to you.

Please select what applies to you.

Referral:

If you have a current referral that is dated within the last 12 months, please tick the box & upload it here.

Consent:

I hereby give my permission to Melbourne Rheumatology Group to access any medical information deemed necessary for my medical care
General Information
Accuracy of Information: I confirm that the information provided on this form is accurate and complete to the best of my knowledge. I will notify the clinic of any changes to my personal or medical information.
Privacy and Confidentiality
Use of Personal Data: I understand that my personal and medical information will be stored securely and used in accordance with applicable privacy laws and regulations.
Disclosure of Information: I consent to the sharing of my medical information with other healthcare professionals involved in my care, as required, and understand that this may include electronic communication where appropriate.
Right to Access: I am aware that I have the right to access my health records upon written request and in accordance with clinic policies.
Treatment and Care
Consent to Treatment: I consent to receiving treatment, including diagnostic tests, therapies, and procedures as deemed necessary by my healthcare provider.
Informed Decision: I understand that I will be informed of the risks, benefits, and alternatives of treatments and have the right to ask questions or refuse any procedure.
Compliance: I agree to follow the treatment plan outlined by my healthcare provider and understand that failure to do so may affect the outcomes of my care.
Billing and Payments
Fees and Charges: I acknowledge that I am responsible for payment of all fees and charges associated with my care, including those not covered by insurance. For any bulk billing Medicare services that are provided, I assign the benefits to the practitioner.
Cancellation Policy: I understand the clinic’s policy on cancellations and missed appointments and accept the potential fees for non-compliance.
Insurance Claims: I authorise the clinic to process insurance claims on my behalf and understand that I am responsible for any outstanding balances not covered by my insurer.
Risks and Limitations
Acknowledgment of Risks: I understand that while all treatments aim to improve my health, outcomes are not guaranteed, and there may be risks involved.
Reporting Changes: I will inform my healthcare provider of any changes in my condition or reactions to treatment promptly.
Use of Artificial Intelligence (AI) in Sessions
Consent to AI Use: I understand that the clinic may use artificial intelligence (AI)-based tools to assist in the evaluation, planning, and delivery of my care. These tools may include but are not limited to letter writing, diagnostic assistance, treatment recommendations, and administrative support.
Transparency: I acknowledge that the use of AI will be fully disclosed during my care, and I will have the opportunity to ask questions or opt out of its use at any time.
Data Security: I am aware that all AI tools used comply with data protection laws and ensure the security and confidentiality of my personal and medical information.
Limitations: I understand that AI tools are designed to assist healthcare providers but do not replace their clinical judgment or expertise.

By signing this form, I acknowledge that I have read, understood, and agree to the terms and conditions outlined above. I also confirm that I have had the opportunity to ask questions and have them answered to my satisfaction.

Your full name

Today's date

Signature

Signature