Patient Information Form

Patient Information

Residential Address

Postal Address

Contact Details


Health Insurance

General Practitioner

Referring Doctor

Next of Kin

Secondary Contact


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 as well as liaising with Medicare, your health fund and other health professionals involved in your care. The Practice has a privacy policy on handling patient information.

I understand the reasons why my information must be collected and am 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.

I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld (e.g. Medical records sent to our practice from a third party.) I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.

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 that I notify this Practice of.

I understand that these consents may be withdrawn at my written request at any time.