Rebecca Young Registration

Why are you attending this practice? *

Who is your GP? *

What is your GP's address? *

Please list other treating doctorsPlease include their name and practice details

PATIENT DETAILS

Title *

First Name *

Surname *

Preferred Name *

Date of Birth *

Sex *

Occupation (optional)

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HomeMobile

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

Do you agree to receive SMS reminders? *

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Do you agree to email correspondence? *

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Medicare Number *Please check this should be 10 digits altogether with no spaces in between

Reference Number *Number next to the patient name

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Type

EMERGENCY CONTACT / NEXT OF KIN

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Do you consent to us giving this person your results and appointment information? *

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If the Medicare rebate should go into this person's account please provide their:

Medicare NumberPlease include the reference number next to the person's name

Date of Birth

MEDICAL AND CULTURAL DETAILS

Do you identify as Aboriginal and/or Torres Strait Islander?

YesNo

Country of Birth *

Is English your first language? *

YesNo

Do you require an interpreter? *

YesNo

Current Medications *Prescriptions, vitamins etc

Do you have any allergies? *Medications, food, materials

Have you ever had a pap smear? *

YesNo

Date of last pap smear *

Was it normal? *

YesNo

Approximate Height *

Approximate Weight *

Please describe

Smoking *

I have never smokedI currently smokeI ceased smoking

Number per day *Current or what you used to before quitting

Alcohol *

I do not drink alcoholI currently drinkI ceased drinking

Number per week *Current or before you quit drinking

Recreational drug use (including marijuana) *

I do not use recreational drugsI currently useI ceased recreational drugs

Times per week *

If you have had any previous pregnancies please complete the following:

Pregnancy 1 - Date

Live Birth

YesNo

MAES

Weight

Type

VaginalCaesarean

Pregnancy 2 - Date

Live Birth

YesNo

MAES

Weight

Type

VaginalCaesarean

Pregnancy 3 - Date

Live Birth

YesNo

MAES

Weight

Type

VaginalCaesarean

Pregnancy 4 - Date

Live Birth

YesNo

MAES

Weight

Type

VaginalCaesarean

More pregnancies

PRIVACY POLICY

This clinic 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 mayproperly assess, diagnose, treat and manage your health care needs. This means we will use the information you provide in the following ways:

Administrative 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 followingthe referrals.
Disclosure to other doctors in the practice, locums and trainees attached to the practice for the purpose of patient careand teaching.
Emergency situations whereby medical officers/hospitals may require access to patient notes for treatment purposes.

CONSENT

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 thequality 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, this clinic will seek my consent prior
I consent to this clinic 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 onthe 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 understand for security purposes the common area at this clinic is under video surveillance.
I understand that my results will be communicated from the treating Doctor via primary sms/ email contact provided and that a phone call from clinic 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.

Full Name *

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Date

Dr Rebecca Young - Sydney Urogynaecologist & Pelvic Reconstructive Surgeon
Level 5,22 Darley Rd, Manly NSW 2095
www.drrebeccayoung.com.au | Ph: 02 9094 3313 | Healthlink EDI drryoung