Patient Form

Patient Registration Form

By completing this form you are giving consent to collect your personal information

Title

Surname

First Name

Email Address

Date of Birth

Sex

Telephone (Home)

Telephone (Work)

Telephone (Mobile)

Home Address

Suburb

State

Postal Address

Suburb

State

Patient's Medicare

Ref:

Expiry:

Parent's Name

Parent's Date of Birth

Parent's Medicare

Ref:

Expiry:

Occupation

Health Fund:

Name

Number

Veteran Affairs:

Type

Workers Comp:

Insurer

Claim Number

Employer

Address

Suburb

State

Usual GP Name

Address

Suburb

State

Phone

Fax

If you have a history with cancer please provide details:

Smoking History

Never smoked Ex-smoker Current smoker

Alcohol Intake

Non-drinker Rarely/light Moderate Heavy

Name of Patient or Individual Granting Consent

Consent to Photography

I hereby consent that photographs be taken of me by Dr Sheanna Maine.

Dr Maine at all times respects patients right to privacy and informed consent for procedures within the practice including photographic records. I understand that these photographs form an essential part of my medical records as well as my pre-operative and post-operative assessment. I understand and consent to my photographs being used by Dr Maine for medical research, teaching and patient education purposes. I understand that I will not be identified by name in any such use of these photographs, however, in some circumstances the photographs may portray features that shall make my identity recognisable.

I give permission to Dr Maine or her staff to contact me by telephone and if necessary leave a message. I have read all of the above and all my questions have been answered.

Do you consent to photography?

Yes, I hereby consent that photographs be taken of me by Dr. Sheanna Maine. No, I do not consent to photography.

Consent to Information Retention

Dr Maine will retain your health information as part of your health service provision. Please read and sign to give approval for this information to be collected and sorted. Your medical information will be used exclusively for providing health care in the following way.

To diagnose your medical problem and provide treatment where necessary;
For administrative purposes in running a Practice,
For communication of your healthcare to other Doctors involved in the provision of your healthcare, and the storing of reports provided to this Practice by other Medical Specialists; and
For billing and collection purposes, including but not limited to compliance with Private Health Fund, Medicare and Health Insurance Commission requirements. You may gain access to your health information by writing to us. If you do not consent to providing us with your health information we may be unable to provide you with a health service.
De-identified information may be used for research purposes. This may include the publication of clinical photographs in research publications.

I consent to Dr Sheanna Maine collecting my health information.

Do you consent to Information Retention?

Yes, I consent to Dr. Sheanna Maine collecting my health information. No, I do not consent to photography.

Digital Signature

Today's Date

Patient Registration Form

Consent to Photography

Consent to Information Retention

QLRC Acknowledgment of Country

OFFICE

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