To whom should the account be addressed if the patient is a child


Medical Information

Please include the dose and frequency

Family History

Lifestyle Health History


Health Information Collection and Use Consent Form

Sydney Gastroenterology and Liver Group respects your right to privacy and we are mindful that the information that you provide to us is personal and private. As a patient or client of this service, 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.

We aim to protect the privacy and secure storage of your health information. No information about you, including the fact that you have attended for a consultation or procedure will be released to anyone outside of the service without your written permission except in certain circumstances (eg. legal related disclosure). You can request a copy of our Privacy Policy, which includes information about the collection, use and disclosure of your health information as well as how to access 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 Medicare and Health Insurance Commission requirements.

  • Disclosure to others involved in your healthcare including treating doctors, counsellors and specialistsoutside this medical practice. This may occur though referral to other doctors, specialists or allied healthprofessionals, or for medical tests and in the reports or results returned to us following referrals.

  • Disclosure to other doctors (including specialists), locums, registered nurses, medical students etc. for thespecific purpose of education, patient care and teaching.

  • For research and quality assurance activities to improve individual and community health care and practicemanagement. In most circumstances, information that does not identify you is used, but should informationthat will identify you be required, you will be informed and given the opportunity to “opt out”.

  • To comply with any legislative or regulatory requirements e.g. notifiable diseases.

  • For reminder or recall letters which may be sent to you regarding your health care and management.

  • For legal related disclosure as requested by a court of law (eg. Subpoena, court order, suspected childabuse or non-accidental physical injury, or in circumstances where we have cause to be seriously concerned for your safety or anyone else)

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. If you have any concerns about the above information. Or wish to restrict access to your personal health information please discuss this with your doctor at the time of consultation.

For further enquiries, please contact T: (02) 9480 6210 F: (02) 8008 1625 E: admin@gastroandliver.com.au

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Sydney Gastroenterology and Liver Group

Suite 213, San Clinic Tulloch
Sydney Adventist Hospital
185 Fox Valley Rd
Wahroonga NSW 2076