New Patient Registration

Who is your GP?

Please list other Doctors who should receive correspondence about your visit.

Patient Details

Name*

Title First Last

Preferred Name

Date of Birth

Sex

Address

Street Address City State Postcode

Phone*

Mobile

Email

Please note: all receipts and patient correspondence will be sent to this email address

Medicare Number

Position on Card

Expiry

Private Health Fund

Membership Number

Hospital Excess

Dept. Vets Affairs Number

Type

Concession Card Number

Type

Emergency Contact / Next Of Kin

Name*

Address

Street Address City State Postcode

Relationship to Patient

Phone*

Do you consent to us giving this person information regarding results and appointments?*

Yes
No

MEDICARE DETAILS

If patient is under the age of 18 please supply the Medicare details of their guardian for rebate purposes

Is the Medicare rebate going into this person's account?*

Yes
No

Next of Kin Medicare No

(Only If they should receive the Medicare Rebate)

Next of Kin - Date of Birth

(Only if they should receive the Medicare Rebate)

DD

MM

YYYY

Digital Photography

(You may change this authorisation at any time)

Do you consent to Q Dermatology using those photographs for educational or publication purposes, provided my identity is protected?*

Yes
No

Medical History

Please list all drug or food allergies (including latex, lidocaine and adhesives):

Privacy Policy

Q Dermatology collects information from you for the primary purpose of providing quality health care. Federal Privacy Law requires your consent to this. We need your personal details and full medical history (which may include photographic records) so that we may properly assess, diagnose, treat and manage your health care needs. This means we will use the information you provide in the following ways:

Adminstrative purposes in running our medical practice, which may include confirmation of your appointment via SMS or email
Billing purposes - including, but not limited to, compliance with Medicare and the Health Insurance Commission requirements.
Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports of results returned to us following the referrals.
Disclosure to other doctors in the practice, locums and trainees attached to the practice for the purpose of patient care and teaching.
Emergency situations whereby medical officers/hospitals may require access to patient notes for treatment purposes.

CONSENT

I understand for security purposes the common area at Q Dermatology is under video surveillance.
I have read the above information and understand the reasons why my information must be collected.
I understand that I am not obliged to provide any information requested, but that failure to do so might compromise the quality of the health care and treatment given to me.
I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld and that an explanation will be given to me in this circumstance.
I understand that if my information is to be used for any purpose other than the above, Q Dermatology will seek my consent prior.
I consent to Q Dermatology using my personal information in the ways outlined above.
I understand that Consultations are not bulk billed &/or not payable by private health insurance, and fees are payable on the day of consultation.
I also understand that if there is a need for a procedure or treatment, there will be additional fee for these.
I also understand that an additional fee is required for a procedure or treatment occurring on the same day as an initial consultation.
I understand that by accepting an appointment at Q Dermatology I agree to adhere to the Dermatologist's instructions and medical recommendations.
I understand that my results will be communicated from the treating Doctor via primary sms/ email contact provided and that a phone call from Q Dermatology staff will follow to plan any associated treatment.
I understand I am responsible to call for my results if I have not had my results confirmed a week after my appointment.
I understand medical providers and staff of Q Dermatology are required to obtain digital photography in relation to my health care.

Consent*

I agree to these terms.*

Signature*