ADHD DOCTORS - NEW PATIENT REGISTRATION FORM

NEW PATIENT REGISTRATION FORM

Given Name *

Surname *

Email *

Mobile Number *

Gender *

MaleFemaleOther

DATE OF BIRTH *

Address *

City *

State *

Postcode *

Who is your regular GP or regular GP practice? Please note that a condition of being a patient at ADHD Doctors is open communication with your regular and previous GPs in writing and by phone. *Please make sure the name written is exactly as shown on your Medicare card.

Occupation *

Ethnicity *

AUSTRALIAN, NON INDIGENOUSABORIGINAL BUT NOT TORRES STRAIT ISLANDERTORRES STRAIT ISLANDER BUT NOT ABORIGINALBOTH ABORIGINAL AND TORRES STRAIT ISLANDEROther

Medicare Card Number *

Medicare Card Ref No *

MEDICARE CARD EXPIRY DATE *

NEXT OF KIN Given Name *

NEXT OF KIN Surname *

NEXT OF KIN phone number *

NEXT OF KIN relationship to you *

Do you smoke? *

YesNoEx Smoker

Do you drink alcohol? *

YesNo

Do you have any allergies? *

YesNo

PLEASE SPECIFY ALLERGIES

PLEASE SPECIFY ALL PAST MEDICAL HISTORY - including any admissions to hospital in the last 5 years - please note that being a patient at ADHD Doctors will require a thorough medical history to be collected from current and previous GPs, pathology centres, imaging locations, pharmacists, My Health Record and hospital records from all states of Australia. *

PLEASE SPECIFY ALL CURRENT MEDICATIONS *

PLEASE SPECIFY ALL RELEVANT FAMILY HISTORY INCLUDING CONDITION(S) AND WHO *

OUR PRIVACY AND MEDICAL INFORMATION

Complying with The Privacy Act, your consent is required for information collected. 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 access, diagnose, treat and be proactive in your health care needs. This means that we will use the information for administrative purposes, billing, disclosure to others involved in your health care; including specialists and other treating doctors outside this practice and disclosure to other doctors in the practice including locums to assist in your medical care. This practice may occasionally be involved in research and quality assurance activities to improve individual and community health care and practice management, in which your consultation may include the presence of a medical student or GP registrar. All information is de-identified. If you wish to opt out of any research undertaken by the clinic - please inform your doctor. We always wish to assure you that your health information is treated with utmost confidentiality. In accordance with medical legislations, except our GP doctors, our staff are not authorized to discuss or provide any test results to you. Under circumstances with a doctor's instruction, staff can provide a copy of results as per your communication preferences. Without a consultation /phone consultation or your verbal/ written consent, doctors will not discuss or provide any test results. Your personal information is kept as an electronical record in the practice secured software system for identification purpose only. The paper containing of your personal information will be shredded and disposed at end of the day.

OUR COMMUNICATION

By signing this form, you acknowledge that appointment reminders, follow-up reminders and report recalls will be communicated via SMS. This is a courtesy service that we offer, it may not be sent on all occasions, and you have the responsibility for making, attending, or cancelling appointments for your recall results. You reserve the right to opt out the SMS service at any time, however, you may not be contacted for recalling the results if your phone number provided is not contactable. You acknowledge the risk if you request the results to be sent by the email you provide.

YOUR RESPONSIBILITIES

Patients are required to return for a consultation to obtain test results or prescriptions. If any results are abnormal and/or require urgent attention, we will contact you. Please make sure ADHD Doctors has your current phone number and address details when booking or settling your account. It is crucial that you understand that this is your responsibility to ensure you make an appointment and return for your results and prescriptions.

ZERO TOLERANCE POLICY

We have a zero tolerance policy for physical violence, racial, verbal or online abuse towards to our staff. Violation of Zero Tolerance Policy will result in your immediate exclusion from our services.

MY HEALTH RECORD

TICK IF YOU DO NOTWANT YOUR HEALTH SUMMARY SHARED / UPLOADED TO MYHEALTH RECORD SERVICES note: if you do not want to participate at all, you need to contact My Health Record Help line: 1800 723 471

How did you hear about our practice *

By signing this form, you are agreed that that any fees are payable before any consultation. Any unpaid outstanding funds will lead to termination of our services. Under Australian legislation, service providers including GPs and allied health providers have rights to terminate the therapeutic relationship under circumstances including breach of our clinic policy or healthy relationship between you and the provider. I am aware and willing to pay the fee involved.

Non-Attendance Policy applies: Non-Attendance without a valid reason or prior notice will incur $50 fee.

Investigations/specialists fees: all fees outside our practice are not within our scope, please double check fees prior to investigations/ specialist appointments.

By completing the field above, I understand and agree to all the conditions for the service provided by ADHD Doctors Tas/WA/Qld/Vic.

TYPE YOUR NAME AND SIGN BELOW *

SIGNATURE OF PATIENT / GUARDIAN *

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DATE FORM SIGNED *

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