Patient Registration Form

Health Fund:
Veteran Affairs:
Workers Comp:

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.

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.