Confidential Patient Information Form

Practice Location *

Bondi JunctionMirandaHurstville

CONTACT DETAILS

Title *

Given Name *

Surname *

Date of Birth *

Address *

Address Line 2

Suburb *

State *

Postcode *

Email Address *

Home

Work

Mobile

Please enter at least one phone number

Occupation *

Employer (Workcover)

Emergency Contact *

Relationship *

Contact Number *

PRACTITIONER DETAILS

Regular Optometrist

Suburb

Regular GP

Suburb

Paediatrician (if applicable)

Suburb

FUND DETAILS

Medicare Number

Ref Number

Expiry Date

Pension Number

DVA Number

Card Colour

Health Fund Name

Member Number

PLEASE ANSWER

I give permission for appointment details to be emailed or texted to the mobile number shown above *

YesNo

I give permission for estimates and/or invoices to me emailed to the above email address *

YesNo

I am aware of my right to access the information collected about me, except in circumstances where access might be legitimately withheld. *

YesNo

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

YesNo

If any changes are made to the consent form at any time I will be made aware of the same and asked to sign a revised consent form. *

YesNo

MEDICATIONS

Are you allergic to any medications? *

YesNo

Please specify

Are you taking any medications? *

YesNo

Please specifyInclude dose and times

Are you taking any blood thinning medications? *

YesNo

Please specifyInclude dose and times

HEALTH HISTORY

Do you suffer from any of the following?

AsthmaDiabetesHigh blood pressureAuto immune condition

Any other health conditions?

Are you a smoker? *

YesNo

Are you pregnant? *

YesNo

Have you had any previous eye conditions or surgeries? *

YesNo

Please specify

FAMILY HEALTH HISTORY

Do you have a family history of any eye conditions? *

YesNo

Do you have a family history of any major health issues? *

YesNo

Collection of Personal Information, HRIP Act 2002 (NSW) and Privacy Act 1988 (Cth)

We acknowledge our obligations under The Health Records and Information Privacy HRIP Act 2002 (NSW) and The Privacy Act 1988 (Cth). These Acts regulate the way in which we collect, hold, use and disclose your information.We are committed to maintaining your personal health information as your medical record is a condential document. It is the policy of this practice to maintain condentiality at all times and maintain the security of your personal health information at all times and to ensure that this information is only available to authorized members of staff or other health professionals as considered necessary in the context of your treatment.

If you would like to read more about our Privacy Policy or the HRIP Act 2002 (NSW) or The Privacy Act 1988 please ask our reception staff.

Responsibility for Fees

In the event where your overdue account is referred to a collection agency and/or law firm, you will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand costs.

Date

Signature *

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