New Patient Form

This general practice collects your information for the primary purpose of providing proactive health care and to enable us to properly assess, diagnose and treat illnesses and medical conditions. In keeping with the Privacy Act 1988 and Australian Privacy Principles, the following information is provided on how your personal information may be used or disclosed and record your consent or restrictions to this consent.

Your personal information will only be used for the purposes for which it was collected or as otherwise permitted by law, and we respect your right to determine how your information is used or disclosed.

By signing below, you (as a patient/parent/guardian) are consenting to the collection of your personal information to be used for the following purposes:

• Administrative and billing purposes in the operation of our general practice.
• Reminder/recall notices for treatment and preventative healthcare issued by telephone, SMS or mail.
• Disclosure to others involved in your health care (e.g. specialists, diagnostic testing) within and outside this medical practice.
• Accreditation and quality assurance and to comply with other legislative requirements.
• For legal related disclosure as required by a court of law.
• For the purposes of research and training only where de-identified information is used.

At all times we are required to take all steps necessary to ensure your information remains confidential. Please complete the details below if you understand and agree to the following statements in relation to our use, collection, privacy and disclosure of your patient information.

I have read the information above and understand the reasons why my information must be collected, and the purposes for which my information may be used or disclosed. I understand that if my information is to be used for any other purpose other, my further consent will be obtained.

I give permission for my personal information to be collected, used and disclosed as described above. I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.