Patient registrationName* Mr.Mrs.MissMs.Dr. Prefix Given names Surname Preferred nameDate of birth*Weight (kg)Height (cm)Mobile phone*Permission for text message Yes No Work phoneHome phoneEmail*Address Street Address Suburb Post code Medicare Card No.Ref. No.ExpiryPensioners No.ExpiryPrivate Health InsuranceMembership No.DVA No.TAC No.Date of accidentWorkSafe Claim No.InsurerContactReferring DoctorName Dr.Mr.MissMrs.Ms. Prefix First Last PhoneAddress Street Address Suburb Post code GP (if not referring Doctor)Name Dr.Mr.MissMrs.Ms. Prefix First Last PhoneAddress Street Address Suburb Post code Emergency contactName Given names Surname RelationshipPhonePrivacy 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:SignatureDate MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
