Andrew Wines Registration

Title *

Surname *

Given Name *

Date of Birth *

Age

Age in weeks/months

Email Address *

Address *

Suburb *

Home Tel

Work Tel

Mobile

Please enter at least one phone number above

Next of Kin *

Relationship *

Mobile *

Referring Doctor *

Referral

Browse

if you have a copy of your referral, you may attach it here. Max file size 5MB.

Family Doctor (if different from referring doctor)

Address of Family Doctor *

Tel *

Physiotherapist's Name

Tel

Address

Podiatrist's Name

Tel

Address

Medicare Number *

Ref No (next to patient name) *

Expiry Date *

Health Fund Name

Membership Number

AS PATIENT IS UNDER 18, the following is required for Medicare claims

Parent / Guardian Full Name *

Parent DOB *

Parent Medicare Number *

Parent Ref No (next to patient name) *

Expiry Date *

Pension / HCC Number

Exp Date

Veterans Affairs (DVA) Number

Worker's Comp / Third Party *

YesNo

Job Title *

Injury Date *

Employer's Name *

Contact Name *

Address *

Tel *

Insurance Company *

Contact Name *

Address *

Tel *

Claim Number *

CONSENT REGARDING THE HANDLING OF MY INFORMATION

We require your consent to collect personal information about you. Please read this information carefully and sign where indicated below.

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways:

Administrative purposes in running our medical practice.
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 or results returned to us following the referrals.
Research and audit. This practice collects clinical information for the purpose of reviewing the results of both operations and non-operative treatments of various diseases and injuries. The information is used to monitor and improve treatments and is part of the requirements for maintenance of specialists qualifications.

I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information.

I understand that I am not obliged to provide any information requested of me, but that my 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. I understand I will be given an explanation in these circumstances.

I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.

I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I notify this practice of.

I have read the consent regarding the handling of my information by this practice for the purposes set out in the form. I consent to the handling of that information subject to any limitations on access or disclosure that I notify this practice of. *

Signature *

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Date

Full Name *