New Patient Information

Name *

First Name

Last Name

Are you registered with Medicare Online? *

If Medicare have your bank account details or they have paid a rebate to you previously, tick Yes. If not, please tick No.

Yes

No

PRIVACY INFORMATION - In accordance with the new government regulations regarding privacy, we are obliged to inform you that a confidential file will be kept by your doctor containing results of your tests and other relevant information. Routinely, information regarding the outcome of this attendance will be forwarded to your referring doctor and/or local doctor and may also be sent to other health practitioners involved in your care. Should you have any concerns regarding this information or if you wish that other doctors not be notified of the outcome of your consultation, please indicate this through the questions below. If you do not sign this form, we may be unable to perform any test, examination or procedure, as we are required by law to keep patient information for a minimum of 7 years. All information we gather will always remain confidential. *

I have read the Privacy Information above

I understand that my information will be held on file by Prof Varcoe. *

Yes

I am happy for reports on my condition to be sent to my referring doctor. *

Yes

No

I am happy for copies to be sent to other health professionals involved in my care, should they be requested: *

Yes

No

I give permission for Prof varcoe to seek medical reports about my condition: *

Yes

No

I give permission for Prof varcoe to use Medow AI transcription during my consultation: *

Yes

No