TOP HEALTH DOCTORS
In compliance with the Privacy Act, we require your consent for your treating doctor/s to us the information provided on this form. This and additional information may be provided to other doctors and/or specialists when requesting x-rays, pathology tests, referrals etc. Patient information will not be released to family members without the patient’s signed/written consent. Due to Medico-Legal reasons, doctors in this practice will notdiscuss test results over the phone. It is your responsibility to arrange a follow-up appointment for discussion of your results.
You must present your Medicare Card/Medicare Receipt and any health care/Centrelink concession cards to reception prior to all of your appointments. Failure to produce a current Medicare Card may result in a fee for your consultation.
Patients will be seen in the following order: (1) Those with an emergency (as determined by Top Health staff/doctors), (2) those with an appointment, (3) and those without an appointment. Given the unpredictable nature of emergencies and patient consultations, appointments are not guaranteed to run on time.
Should you decide to seek treatment elsewhere, you may request copies of your notes to be transferred. Please note, there is a $25.00 (+GST) transfer fee in order to cover costs for photocopying and postage and handling (registered mail only).
* * PATIENT’S DETAILS * *
Title: ______Given Name:______Surname: ______
Preferred AKA:______D.O.B. _____/_____/______Gender: Male Female
Address: ______Suburb:______Postcode: ______
Home Phone: ______Work Phone: ______Mobile:______
Email Address: ______
Occupation: ______Marital Status: ______
Country of Birth: ______Ethnic Background: ______
Are you aboriginal? Yes No Are you Torres Strait Islander? Yes No Registered for Closing the Gap Program? Yes No
Medicare No: ______Reference No(the number before your name):___ Expiry Date: __ __ / ______
Healthcare/Concession Card(Please circle): ______Expiry Date: __ __ /__ __ / ______
DVA No: ______Colour : Gold White
Next of Kin Contact: Given name: ______Surname: ______
Next of Kin Contact No: Home:______Mobile: ______Relationship: ______
Emergency Contact: Given Name: ______Surname: ______
Emergency Contact No: Home:______Mobile): ______Relationship:______
Do you drink alcohol? Yes No How Much ______daily/weekly/monthly/socially
Do you smoke? Yes No How Many ______daily/weekly/ monthly/socially
What are you allergic to (including reactions): ______
Please list any current medications (including over the counter medicine and vitamins): ______
______
Social History: (including any sports, hobbies and other interests): ______
How did you hear about this practice?
Google / Instagram / Chemist / Yellow PagesYahoo / Passing by / Street Signage / White Pages
Facebook / Word of Mouth / Other Medical Centre: / Others:
Patient Medical History: Please list any current or past medical conditions or operations
Condition / Yes / No / Condition / Yes / No / Operation / Yes / No / OthersAsthma / Heart Disease / Skin Cancer
Diabetes / Heart Attack / Appendix
Blood Pressure / Stroke / Gallbladder
Cancer (Type) / Bleeding Disorder / Orthopaedic
Family Medical History: Please list any of the following conditions in your family
Condition / Yes / No / Who / Condition / Yes / No / Who / OthersHeart Disease/Attack / Bleeding Disorder
Stroke / Cancer (Type)
Diabetes / Psychiatric
Breathing Problems / Genetic Disorde:(Type)
This practice has a recall & reminder system, we also participate in the National & State reminder systems eg: pap smear & Australian Childhood Immunisation Register.
Do you want to participate? Yes No
Do you wish to participate on communication via SMS? Yes No
Do you wish to participate in the E Health (electronic health record) Scheme? Yes No
All appointments at this practice require 1.5 hours notice of cancellation. Otherwise there will be a $50 non-attendance fee payable. Cancelling appointments that you cannot make allows time for other patients who need to see a Doctor. We thank you for your cooperation.
I acknowledge I have agreethe policy regarding appointment cancellations. Yes No
Signature of Patient or Guardian: ______Date: __ __ / __ __ / ______
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Patient Privacy Information: To provide a high standard of medical care, we need to collect personal information from our patients. This information is usually collected from the patient, but may be collected from family and other health care providers with the patient’s consent. At times, some of this information needs to be shared with other health care providers or we may be legally bound to disclose personal information. From time to time, your consult may include the presence of a medical student or GP registrar as our doctors are actively engaged in teaching training doctors. All persons accessing your personal health information, are bound by confidentiality. Please do not hesitate to discuss any concerns, questions or complaints about any issues related to your privacy of your personal information with your doctor.
Thank you for your time taken to complete the Patient Form.
Please bring it with you to your appointment.
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