Gold Coast Heart Centre Patient Information Form

PATIENT DETAILS

  GP DETAILS

MEDICARE / HEALTH FUND DETAILS

NEXT OF KIN DETAILS & AUTHORITY

If Yes, please sign and date: 

If No, please complete below with your nominated contact information:

Patient Authority – Nominated Contact (if not Next of Kin)

TELEPHONE CONSENT

For administration purposes we may be required to contact you by phone. Do you authorise our staff to:

SMS CONSENT

Our practice uses an SMS reminder system to assist in the management of your appointments.    Do you consent to the transmission of SMS (mobile text messages), for the purposes of:

You may withdraw your SMS consent at any time by notifying our practice in writing.  

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs.  This means we will use the information you provide in the following way – please see disclosure statement below:

DISCLOSURE AND COLLECTION STATEMENT: 

I consent to the disclosure to and collection from medical/specialist practitioners, allied health practitioners and institutions that may require information about my medical history but only to the extent necessary to assess/treat the particular condition that I have consulted the medical/specialist practitioner about. Disclosure and collection may also be required for administrative purposes in running our medical practice including Medicare, DVA and non-medical information for debt collection if applicable.

EMAIL CONSENT

I consent to disclosing my medical records to medical practitioners, hospital departments and other providers directly involved in my health care management outside of this practice, by email.

I consent to corresponding with the Administration Staff at Gold Coast Heart Centre by email regarding any upcoming appointments, referral reminders and general administrative and accounting purposes.

I am aware that by sending my medical records via email and corresponding with administration at Gold Coast Heart Centre, that there may be a risk (as with any other document) that it could be read by someone other than the intended recipient.

I am aware that at any time I can withdraw my consent in writing.