New Patient Form

How did you find out about our Medical Centre?

Word of mouthGoogleWebsitePharmacyFlyerHealthEngineSignage outside practiceFriends/FamilyOther

Vaccinations:

Please indicate if you are up to date with the following immunisations;

Influenza (Flu)Hepatitis A / Typhoid (Bali/Thailand/Asia travel)Pneumococcal (Pneumonia >65yrs)Boostrix (Whooping cough)Tetanus (10 year protection)Zostavax (Shingles 70-79yrs)

Preventatitive Health

Please tick the relevant box if you have had any of the following preventative health measures;

GP Management Plan (Chronic Disease patient’s eg. Heart disease / Diabetes / Asthma / Arthritis)40-49 year old health check if at risk of diabetes45-49 year old health check if at risk of any chronic diseaseOver 75 year’s health check (Recommended each year)Women’s check; CST smearBowel Cancer screening test (Recommended for all patients over 50 each year)

Alma Village Medical Centre 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.

This means we will use the information you provide in the following ways:

• Administrative purposes in running our medical practice.

• Billing purposes, including compliance with Medicare Australia requirements.

• Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice.

• To contact you for the purposes of recalls & Reminders via phone, sms or mail.

Patient information shall not be released to a third party without the expressed consent of the patient.

Patient Consent

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. I understand I will be given an explanation in these circumstances.

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.