Patient Data Sheet


To be completed only after appointment has been made.

My appointment is (*)


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Last

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First

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Middle

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DATE OF BIRTH

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OCCUPATION.

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ADDRESS

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P/code

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TELEPHONE

HOME

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WORK

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MOBILE

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MARITAL STATUS

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MEDICARE NUMBER

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NEXT OF KIN

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RELATIONSHIP

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PHONE

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REFERRING DOCTOR

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DATE OF REFERRAL

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ADDRESS

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P/CODE.

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USUAL FAMILY DOCTOR.

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ADDRESS

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P/CODE

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TELEPHONE

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PRIVATE HEALTH FUND

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M/Ship No

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DEPARTMENT OF VETERANS AFFAIRS: Gold Card Number

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Pensioner/Healthcare card Holder

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IMPORTANT
PRIVACY POLICY From 21/12/01, the Federal Privacy Act of 1988 has been amended to apply to all doctors in private practice. The National Privacy Principles (NPPs) require that fully informed voluntary consent is obtained before or as soon as practical after the collection of health information. This is particularly important for “secondary purposes” such as auditing surgical results and carrying out clinical research etc. These quality assurance activities should be a normal part of good surgical practice. Record keeping for plastic surgery may be in the form of clinical photographs. The privacy of individual patients is strictly maintained when reporting the results of audits or research to the medical profession. You may request access to your records.


FEES
Generally this practice bills at AMA rates, this means there will be an out of pocket fee even with private insurance. We are a pay on the day of consultation surgery.

Please contact our main rooms on 9340 5844 to obtain the current fees for consultations. Fees are updated on the 1st November each year.

If a procedure needs to be performed, a detailed list of costs will be provided PRIOR to the surgery.

Procedures under local anaesthetic have an additional procedure room fee – this account is NOT claimable from Medicare or your private fund. Procedure room fee is payable on day of surgery.

Please do not hesitate to discuss your financial position with Miss Read if necessary.



(*)

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