DEMOGRAPHIC FORM - Pelvic Pain Clinic

General Information

Patient’s Personal Details on Medicare card:

First name *

Middle name

Surname *

Preferred name

Date of birth *

Email Address *

Home address (House/Unit number, Street, Suburb, Postcode) *

Postal Address

Home phone

Work phone

Mobile number *

Gender with Medicare *

MaleFemale

Preferred pronoun: *

HeSheTheyOther

Sexual Orientation - Do you think of yourself as: *

Medicare Number *

Medicare Ref No. next to name: *

Medicare Expiry: MM/YY *

Healthcare/Pension Card No:

Expiry: DD/MM/YY

Ethnicity e.g. country of origin *

Do you identify as: *

Aboriginal Torres Strait Islander Aboriginal/Torres Strait IslanderNeither

Primary language if not English:

IMPORTANT! If you have any copies of previous tests/reports/specialist letters please email those to us: admin@northsidehealthnt.com.au

Emergency Contact Information

Emergency contact First Name *

Emergency Contact Surname *

Phone *

Emergency contact’s relationship to you *

Account Holder Details - The account holder is responsible for paying invoices and will receive Medicare rebates.

If the patient is NOT the account holder, please complete the following section (eg. Parent of a child patient):

Account Holder Name:

Account Holder's Date of Birth

Account Holder's Postal Address:

Account Holder's Medicare Number:

Account Holder's Ref No. next to name:

Account Holder's Expiry: MM/YY

Consent

CONSENT TO COLLECT PATIENT INFORMATION

This medical practice collects information from you for the primary purpose of providing quality healthcare. We require you to provide us with your personal details and medical history so

that we may properly assess, diagnose, treat and be proactive in your healthcare needs. We take confidentiality seriously. We will use the information you provide in the following ways:

Administrative purposes in running our medical practice.
Billing purposes including compliance with Medicare and Health Insurance Commission requirements.
Communicating to others involved in your healthcare including treating and referring doctors and specialists outside this medical practice, as advised by you.
Seeking intervention in an emergency if your safety or someone else’s is at risk. Confidentiality will be breached if you or someone else is at imminent risk of injury or harm.
Confidential discussions with other practitioners to seek advice or discuss health issues.
De-identified data extracted for statistical purposes where patient personal details are not visible.
I understand the reasons why my information must be collected.
I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the healthcare and treatment given to me. I am aware of my right to access the information collected about me, except in some circumstances where access may be withheld. I understand I will be given an explanation in these circumstances.
I understand that if my information is to be used for any purpose other than the above, my consent will be sought.
I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.

I confirm that above information I have provided is true, complete and accurate. *

Do you consent to receiving appointment reminders via SMS? *

YesNo

Do you consent to having your medical information such as referrals transmitted via email? *

YesNo

Signature

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Date *