Patient Registration Form

Patient Details

Title

Pronouns

Patient First Name *

Patient Last Name *

Known As/Preferred Name (if different)

Date of Birth *

Gender *

Male FemaleIntersex

Mobile Phone No.

Home Phone No.

Email Address

Address *

Suburb *

Postcode *

EMERGENCY CONTACT/NEXT OF KIN - Name *

EMERGENCY CONTACT/NEXT OF KIN - Relationship *

EMERGENCY CONTACT/NEXT OF KIN - Contact Phone No. *

EMERGENCY CONTACT/NEXT OF KIN - Email

Tick if Enduring Power of Attorney (Medical)

Account Information

Patient Medicare No. (enter N/A if no Medicare card) *

Ref No. (next to patient name on card)

DVA No. (if applicable)

DVA Card Colour

GoldWhite*

*White Card condition covered

Pension No.

*Discounts only apply to Age/Disability Pension Holder (Blue Card)

Pension Card Type

Card Colour

Private Health Fund *

Membership No. (include patient reference no.)

Private Health Insurance Type

Hospital onlyExtras OnlyHospital and ExtrasBasic Hospital Cover Only

Have you held your current policy with this insurance fund more than 12 months?

YesNo* (Note: You may not be covered for inpatient procedures)

* Date policy started (if less than 12 months)

Account Holder Details (if differrent to patient or patient under 18 years old)

Person responsible for account

Account Holder Date of Birth

Account Holder Relationship to Patient

Account Holder Medicare No. and Ref No.

Tick if Enduring Power of Attorney (Medical)

Third Party Accounts (Workcover/TAC/Other)

Third Party Billing (if applicable) - Name of Employer / Insurer

Claim Manager Name / Contact

Claim No.

Date of Accident / Injury

Social & Medical History

Occupation *

Height (cm) *

Weight (kg) *

Do you smoke cigarettes? *

NoYes*

Have you ever smoked cigarettes? *

NoYes*

*If yes - how many cigarettes per day?

Do you drink alcohol? *

NoYes*

Have you ever drunk alcohol? *

NoYes*

*If yes - how many glasses? (per day/week)

Current Medications (include dosage if known) *

Allergies

Previous Endoscopic Procedure/s

YesNo

Upload Endoscopy reports and other relevant radiology and pathology results

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List ALL with date and type of procedures

Family History of significant / chronic illness

Referrer's Details

Name of Referring Doctor *

Practice Name and Suburb

General Practitioner Name (if different from referring doctor)

Other relevant treating Practitioners / Specialists

Upload Referral letter and other relevant correspondence

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Privacy Policy and Collection and Release of Medical Information

Collection of personal information - Gastroenterology Specialist Care (GSC) and your individual health practitioner/s collect relevant and necessary information such as contact information, personal details, health information and medical history, so as to properly assess, diagnose, treat and be proactive in your health care needs, as well as for administrative purposes such as for billing and reminders regarding your health care and management.

Information collected as part of the medical consultation will be contained in the medical record which remains the property of the individual health practitioner/s and is used only to assist in the comprehensive assessment and management of the patient. You may gain access to your information on request. This information may be stored on the GSC computer medical records system and/or in handwritten medical records.

Wherever practicable, information will only be collected from you personally, however occasionally may be collected from other sources such as other health care providers, medical practices, or hospitals. Information may be collected by medical or non-medical staff in written or verbal format.

To ensure that your personal information is accurate, complete, up to date and relevant we request that you advise if any of the information held about you is incorrect or out of date. Your consent is required to collect personal information about you and to use the information you provide in the following ways:·

Disclosure to others involved in your care including treating doctors or specialists. This may occur through referral to other doctors or for medical tests, and in the reports or results returned following referrals.
To comply with any legislative or regulatory requirements eg. notifiable diseases.

You can decline to have your health information used in all or some of the ways outlined above but this may influence the ability to manage your health care and to provide the best outcome for you.

Recording of Consultations

For the purposes of documentation and to ensure accurate record-keeping, your consultation may be recorded via either voice or visual recording device. This recording is for GSC practitioner use only and will not be released to any third party without your specific written consent to do so.

Privacy Policy - GSC and your individual health practitioner/s aim to protect the privacy of health information in accordance with the Gastroenterology Specialist Care Privacy Policy and the Health Records Act 2001. A copy of this Privacy Policy can be obtained at www.gastrosc.com.au

I have read and understood the Privacy information and Consent details above *

I authorise the collection and sharing of information in accordance with the above *

Billing

Gastroenterology Specialist Care provides administrative support for individual health practitioners.
Patient fees are billed privately (not bulk-billed), except at individual practitioner discretion
All accounts are payable in full on the day of consultation, or prior.
In the unlikely event your account is overdue for more than 90 days, you may be referred to a collection agency and/or law firm. You will be liable for all costs which may be incurred, including additional debt collection costs.
Payment via credit/debit card only (no cash).
Where applicable, paid accounts will be submitted to Medicare for a rebate on your behalf (provided you have a current referral and Medicare card).
Endoscopic procedures may incur a gap fee. You will provided with an Estimate of Fees prior to any procedure.
Cancellation fees may apply to appointments cancelled within 24 hours of scheduled time, or for failure to attend appointments.

I have read and understood the Billing arrangements as above *

I confirm that the above information is correct and accurate at the time of signing

Patient Signature *

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Date *

Consent - Sharing of Information

Patient Name *

Patient D.O.B *

I agree to the sharing of relevant information between my health practictioner and Gastroenterology Specialist Care, as well as other members of my healthcare team including but not limited to; General Practitioner, other treating Doctors/Specialists, allied health, hospitals, radiology and pathology providers. *

I consent to my health practitioner and/or Gastroenterology Specialist Care requesting, receiving and sharing information relating to my medical history, results and correspondence. Information may be requested and shared via email, fax, verbally or hard copy. *

Signature *

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Date *

Printed Name *

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