New Patient Form

Patient Information

Patient Information

Patient Information

Next of Kin

Emergency Contact Information

Health Professionals for correspondants

Patient Declaration

Consent

As a patient of our medical practice 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. We aim to protect the privacy and secure storage of your health information. You can request a copy of our privacy policy, which includes information about the collection, use and disclosure of your health information.

I AUTHORISE JOHN FLYNN CARDIOLOGY to use this information I have provide in the following ways:

1. Administrative purposes in running our medical practice
2. Billing purposes, including compliance with Medicare, Health Insurance Commission and/or Third Party requirements.
3. Disclosure to others involved in your health care, including treating doctors and specialists outside this practice. This may occur through referral to other doctors, or for medical tests and in the reports returned to us following the referrals.
4. Disclosure to other doctors, allied health workers and nurses who may work in the practice, including Locums and for the purpose of patient care and accreditation.

By signing this document below, I agree to the following:

• I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information.
• 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 health care and treatment given to me.