PULSE HOLISTIC MEDICAL CENTRE
NEW PATIENT REGISTRATION FORM
We need this information to provide you with the best quality of care. Our practice follows the guidelines of The Royal Australian College of General Practitioners Handbook for the management of health information in private medical practice. This means your personal information is kept private and secure, as required by federal and state privacy laws.
PATIENT DETAILS
Surname______Given Names______Title_____
Date of Birth ___/___/___
Home Address ______
Postal Address ______
Phone (home)______(mobile) ______(work) ______
Email address ______
Private Health Fund______Number______
Medicare Card Number:______Ref No:_____Expiry Date___/_____
Veterans’ Affairs Card Number______Expiry Date___/___/___
Pension Card Number______Expiry Date___/___/___
Health Care Card Number______Expiry Date___/___/___
Emergency Contact (next of kin)
Name______Relationship to you______
Phone (home) ______(mobile) ______(work) ______
Do you identify as:
1. Aboriginal or Torres Strait Islander origin? No Yes If yes, are you registered for Close the Gap___
2. Other Cultural background? No Yes ______
Do you have any Known Allergies: Yes No
List of Allergies
______
Due to the difficulty of filling last minute cancellations, we respectfully request 24 hours notice. If this request is not fulfilled it will be necessary to charge 50% fee for missed appointments.
P.T.O to sign privacy form
PULSE HOLISTIC MEDICAL CENTRE
PRIVACY ACT AMENDMENT (2000)
Dear Patient
We value your privacy. All information about you, held in this practice, is kept in the strictest confidence. With the introduction of the Privacy Act Amendment (2000) in December 2001 we remain committed to protecting your privacy and are now asking for your express consent for the use and disclosure of your personal health information in the course of your health care. This consent allows those involved in your health care access to the information necessary to continue the high standard of health service you have come to expect of us.
CONSENT FOR
USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION
IN THE DELIVERY OF HEALTH SERVICES
I consent to the use of my personal health information by the above-named practice and other health providers involved in my medical treatment and health care.
I consent to the disclosure of my personal health information by the above-named practice to other health providers directly or indirectly involved in my personal health care or medical treatment.
______
Personal Declaration. Declaration on behalf of another person
Printed name: unable to comprehend or complete a
______personal declaration.
Signature: Patient name:
______
Date: Signed for and on behalf of the above patient.
______Name______Signature______
Relationship to patient______
Emailing Patients Policy
Emailing has become a pivotal source of communication in today’s society. Pulse Holistic Medical Centre has introduced an email service to enable patients to receive results and correspondence from the practice only as directed by the Doctor via email.
This email service is limited to the following:
- Letter of notification that the patient is due for a review or PAP smear
- Letter of notification that the patient is needing to be seen non-urgent regarding test results
- Patient results as per doctors orders
Emails are sent over the internet and as such may not be secure. Once your results are in your care, the surgery cannot take responsibility.
I______understand and consent to the above. Signature______