CAMERON PARK MEDICAL PRACTICEWALLSEND MEDICAL PRACTICECLARENCE TOWN MEDICAL PRACTICEPATERSON MEDICAL PRACTICE

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    Next of Kin :

    Emergency Contact :

    Do you Identify yourself as :
    AboriginalTorres Strait IslanderAustralian Non-AboriginalOther

    Smoker :
    YesNo

    Alcohol :
    YesNo

    Allergies :
    YesNo

    Marital Status :
    SingleMarriedDivorcedWidowedDefacto

    Past History :
    DiabetesHypertensionHeart DiseaseStrokeCancerAsthmaEmphysemaDepression

    Family History :
    DiabetesHypertensionHeart DiseaseStrokeCancerAsthmaEmphysemaDepression

    Health Information Collection and Use Consent :

    We require your consent to collect personal information about you and to use the information you provide in the following ways :-

    • Administrative.

    • Billing.

    • Disclosure to others involved in your healthcare including treating doctors and specialist outside this medical practice.

    • Other doctors within this practice.

    • Deidentified for research and quality assurance activities.

    • To comply with any legislative or regulatory requirements e.g. notifiable diseases.

    • For reminder letters which ay be sent to you regarding your health.

    Reminder System :

    This practice takes a preventative approach to your health. You may receive phone calls, letters or be reminded at your next visit of on-going follow-up for preventative care as well as SMS appointment reminders.
    Thank you for taking the time to complete this form.

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