MARYLAND 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.