MUNDARING MEDICAL CENTRE
Patient Demographic / Health Summary
Welcome to Mundaring Medial Centre. We are omitted to providing our patients with the best care.To do thisit is essential that your medical records are accurate and up to date.
Please assist us with thecompletion of the following.
(P.S If you are a new patient and you have booked an online appointment via you may complete this form and email it prior to your appointment to save you time You will be required to sign and date this form at arrival of your appointment. Please bring your medicare card/ health care cards for identification. If you are on any medication please bring with you or your medical history. This form will be held at reception).
Title: Dr ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐Gender: M ☐ / F ☐ / Do You Currently Smoke? Yes☐ No ☐
How many cigarettesClick or tap here to enter text.
Have you ever tried to quit? Yes ☐/ No ☐
Year?Click or tap here to enter text.
First Name: Click or tap here to enter text.
Surname: Click or tap here to enter text.
Date of Birth: Click or tap here to enter text. / Have you ever smoked? Yes ☐ / No ☒
Country of Birth: Click or tap here to enter text.
Indigenous / Torres Strait Islander
Yes☐ / No ☐ / Do you drink Alcohol? Never☐/ Less than monthly☐/ 1-2 days per week☐ / 3-4 days a week ☐ /5-6 days a week☐
Primary Language: Click or tap here to enter text.
Occupation: Click or tap here to enter text. / Do you drink 6 or more standard drinks on one occasion?Never☐/ Less than monthly☐ / Monthly☐ / Weekly☐ / Daily☐ / Almost Daily☐
Address including postcode: Click or tap here to enter text. / Does your alcohol consumption concern you?
Yes ☐ / No ☐
Home Phone: Click or tap here to enter text.
Mobile: Click or tap here to enter text.
Work Phone: Click or tap here to enter text. / Current Medications– please include over the counter medications/vitamins please bring these with you. Click or tap here to enter text.
Medicare Number: Click or tap here to enter text.
Reference: Click or tap here to enter text.
Expiry Date: Click or tap here to enter text. / Do you have any Allergies? Yes ☐/ No ☐
Nil known☐ (please tick)
Medications:Click or tap here to enter text.
Food:Click or tap here to enter text.
Other:Click or tap here to enter text.
Concession card number:
Click or tap here to enter text.
Expiry date: Click or tap here to enter text.
DVA number: Click or tap here to enter text.
Expiry date: Click or tap here to enter text. / Family Medical History – Have any members of your family ever had?
Diabetes:☐/Heart Disease☐/Asthma☐/Cancer☐/Mental Illness☐ /Hypertension☐
Private Health Fund:
Click or tap here to enter text.
Member Number:
Click or tap here to enter text. / Past Medical History
Year:Click or tap here to enter text.
Condition/s: Click or tap here to enter text.
Past Surgical History
Year: Click or tap here to enter text.
Procedure/s: Click or tap here to enter text.
Surgeon – if known: Click or tap here to enter text.
Name of Next of kin: Click or tap here to enter text.
Date of Birth:Click or tap to enter a date.
Relationship: Click or tap here to enter text.
Phone No: Click or tap here to enter text.
Emergency Contact Details - (friend, relative or same as above) Click or tap here to enter text.
Date of Birth: Click or tap to enter a date. / Immunisations – are they up to date?
Tetanus - Yes ☐ / No ☐
Influenza - Yes ☐ / No ☐
Hepatitis B - Yes ☐ / No ☐
Hepatitis A - Yes ☐ / No ☐
I provide my consent for Mundaring Medical centre to collect, use and disclose my personal and health information as outlined in the leaflet provided by the PRIVACY ACT (1988) – Privacy Agreement (Private Sector) Act 2000.
Name: ………………………………………………… Date:…… /……/…………
Signature: …………………………………………….
ALL PATIENTS TO READ AND SIGN PRIOR TO THEIR APPOINTMENT
All accounts are payable on the day of consultation.
Declaration:
I understand that other patients are waiting for an available appointment. I agree that:-
- If I am unable to attend my appointment, I will give a minimum of 2 hours’ notice of my cancelation.
- If I do not cancel my appointment or fail to attend I may be charged a fee for my missed appointment.
- My account is to be paid on the day of consultation. An administrative fee of 20% will be incurred if accounts are outstanding longer than 90 days
and I shall be responsible for all collection fees incurred.
In the event of a Worker’s Compensation / Public Liability and Motor Vehicle Accident Claim –
- I will be personally responsible for payment of all accounts incurred b me in relation to medical treatment for injuries sustained in the event that
liability is denied or placed in dispute by the Employer or Insurance company.
- I take full responsibility for costs of any reports produced by the doctor in the event the liability has been denied.
I hereby authorize Mundaring Medical Centre to divulge to my employer and /or employer’s insurer, information relation to my workers compensation / MVA claim or public liability claim. I understand that Mundaring Medical Centre owns the copyright and all legal right to my medical records whether created or stored at the medical centre.
Name: (PRINT) …………………………………………
Signature at centre: ………………………………………. DOB: …… /……/…………
Today’s Date: …… /……/………… Witnessed by: ………………………………….
Please tick: Workers Compensation ☐ MVA☐ PublicLiability☐ Neither☐
Mundaring Medical Centre
Suit 5 / 5 Nichol Street Mundaring WA 6073
Health Information Collection and Use
Consent Form
As a patient of our medical practice we require you to provide us with your personal details and a full medical history, so that we may properly assess, diagnose, treat to be proactive in your health care needs.
We aim to protect the privacy and secure storage of your health information. You can request a copy of our privacy policy, which includes information about the collection, use and disclosure of your health information.
We require your consent to collect personal information about you and to use the information
you provide in the following ways. Please read this consent form carefully, and sign where indicated below.
- Administrative purposes in running our medical practice.
- Billing purposes, including compliance with Medical and Health Insurance Commission requirements.
- Disclosure to others involved in your healthcare including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medial tests and in the reports or results returned to us following referrals.
- Disclosure to other doctors I the practice, locums etc. attached to the practice for the purpose of patient care and teaching.
- For research and quality assurance activities to improve individual and community health care and practice management. Usually information that does not identify you is used but should information that will identify you be required you will be informed and given the opportunity to “opt out” of any involvement.
- To comply with legislative or regulatory requirements e.g. notifiable diseases.
- For reminder letter which may be sent to you regarding your health care and management.
You can decline to have your health information used in all or some of the ways outlined above but it may influence our ability to manage your health care to provide the best outcome for you.
I have read the information above and understand the reasons why my information must be collected.
Name: ………………………………………………....
Date: ……/………/…………
Signature ………………………………………………