Patient registrationName* Mr.Mrs.MissMs.Dr. Prefix Given names Surname Preferred name Date of birth* Weight (kg) Height (cm) Mobile phone* Permission for text message Yes No Work phone Home phone Email* Address Street Address Suburb Post code Medicare Card No. Ref. No. Expiry Pensioners No. Expiry Private Health Insurance Membership No. DVA No. TAC No. Date of accident WorkSafe Claim No. Insurer Contact Referring DoctorName Dr.Mr.MissMrs.Ms. Prefix First Last Phone Address Street Address Suburb Post code GP (if not referring Doctor)Name Dr.Mr.MissMrs.Ms. Prefix First Last Phone Address Street Address Suburb Post code Emergency contactName Given names Surname Relationship Phone Privacy PolicyPRIVACY POLICY: On 21/12/2001 the Federal Privacy Act 1988 was amended to apply to all doctors in private practice. The National Privacy Principles (NPPs) require that fully informed voluntary consent is obtained before or as soon as practical after the collection of health information. This is particularly important for ‘secondary purposes’ such as auditing clinical results and carrying out clinical research etc. These quality assurance activities should be a normal part of good medical practice. Record keeping may also be in the form of clinical photographs. The privacy of individual patients is strictly maintained when reporting the results of audits or research to the medical profession. You may request access to your records. Please discuss concerns about the privacy of your personal information with Dr Dwyer.I have read, understood, and agree with the above policy on privacy, and am aware of the Fee Structure:Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
