REGISTRATION FORM

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SURNAME
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GIVEN NAMES
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WORKCOVER/TAC CLAIM/VETERANS AFFAIR? Y/N Claim No.
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REFERRING DOCTOR
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LOCAL DOCTOR
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FEE POLICY The fees charged in Mr. Burge’s practice are usually based on the A.M.A. recommended rates. Some fees are higher and these reflect the degree of difficulty of your particular surgery, the time necessary in consultations and subsequent surgery, and rises in indemnity insurance. GST applies to all purely cosmetic consultations and procedures where there is no Government item number. You will always be advised of surgical costs beforehand.

PRIVACY ISSUES This Practice complies with the Victorian Health Records Act and the Commonweath Privacy Act. We have a detailed privacy policy which can be viewed on request.

Essentially, Mr. Burge will be asking you personal information regarding your health in order to help treat you appropriately. He will need to make records and often take photographs which are essential in your treatment. These details are filed and kept private and secure. Your referring doctor and other relevant medical specialists will be informed of your diagnosis and progress in writing, but you can indicate if you have any reservations about this.

Photographs are often used for planning your procedures and follow-up. Also, they may be used occasionally for teaching, auditing results and clinical research, but only within the medical profession. Privacy is strictly maintained when reporting any results. Photographs would not be used in any publication (medical or otherwise) without your specific additional written permission.

Post-operative results may be shown to other patients to help them come to a decision but you can ask that this not be done if you wish. Photographs used for this purpose have no identification.

In general a copy of your records is available to you at any time (but there may be a charge for copying and retrieval).

*I have read the above Fee Policy and Privacy Issues Statement. I consent to the taking and use of my medical records as described. I also agree to pay the costs of consultations and any surgical procedures performed.
My appointment is (*)
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