Red House Paediatrics

Patient Registration Form

PATIENT DETAILS

First Name *

Known As / Preferred name (if different to given name)

Last Name *

Address *

Suburb *

Postcode *

Postal Address (if different)

Date of Birth *

Sex *

MaleFemaleOther

Please specify if other: ..............................................................

Preferred Pronouns:

Medicare No.

Reference No. (next to name on Medicare card)

Medicare Expiry

PARENT/GUARDIAN 1 - Person responsible for account

First Name *

Last Name *

Relationship to patient *

Address (if different to patient)

Phone *

Date of birth *

Occupation

Medicare No.

Reference No. (next to name on Medicare card)

PARENT/GUARDIAN 2 / EMERGENCY CONTACT

First Name *

Last Name *

Relationship to patient *

Address (if different to patient)

Phone *

Date of Birth *

Occupation

SIBLINGS OF PATIENT

Name and year of birth of siblings

THIRD PARTY BILLING (if applicable)

Name of Organisation

Case Manager

Contact Details

If there is a third party taking resposibility for the account, pre-approval is required and an application form will need to be completed by the third party at least one-week prior to he appointment date.

REFERRING DOCTOR DETAILS

Referrer Name

Clinic/Address

General Practitioner (if different)

Other relevant Medical Practitioners involved in the patient's care

DOCUMENTS

Please upload any relevant documents (if applicable)

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PRIVACY POLICY AND COLLECTION AND RELEASE OF MEDICAL INFORMATION

Collection of personal information

As a patient of our medical practice we collect relevant and necessary information such as contact information, personal details, health information and medical history of your child, so that we may properly assess, diagnose, treat and be proactive in your child’s health care needs, as well as for the management of our Practice, such as for billing purposes and reminders regarding your child’s health care and management.

The information collected as part of the medical consultation will be contained in the medical records and used only to assist in the comprehensive assessment and management of your child. You may gain access to your child’s information on request. This information may be stored on our computer medical records system, recorded and/or hand written. If at any stage you wish to revoke your consent for recording consultatitions, please do so in writing to the Practice Manager.

Wherever practicable we will only collect information from you personally, occasionally we may collect information from other sources such as other health care providers, medical practices or hospitals. Information may be collected by medical or non-medical staff of our practice, in written or verbal format.

We endeavour to ensure that your personal information is accurate, complete, up to date and relevant. We request that you advise if any of the information we hold about you or your child is incorrect or out of date.

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

Disclosure to others involved in your child’s care including treating doctors, specialists outside this medical practice or the child’s school. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following referrals.
Disclosure to other doctors in the practice, locums etc. attached to the practice for the purpose of patient care and teaching.
For research and quality assurance activities to improve individual and community health care and practice management.
To comply with any legislative or regulatory requirements eg. notifiable diseases.

You can decline to have your child’s health information used in all or some of the ways outlined above but this may influence our ability to manage your health care to provide the best outcome for your child.

Privacy Policy

We aim to protect the privacy of health information in accordance with Red House Paediatrics Privacy Policy and the Health Records Act 2001. A copy of our Privacy Policy can be obtained from our Practice or on our website www.redhousepaediatrics.com.au

I have read and understood the Privacy information and Consent details. *

I provide consent to the patient consultation being recorded exclusively for medical documentation and treatment purposes *

I authorise collection and sharing of information in accordance with the above.

BILLING

Red House Paediatrics is a private practice.
All accounts are payable in full on the day of consultation.
In the unlikely event your account is overdue for more than 90 days, you may be referred to a collection agency and/or law firm. You will be liable for all costs which may be incurred, including additional legal demand/administration costs.
Once you account is paid, in most instances it can then be submitted to Medicare for a rebate (provided you have a current referral and a current Medicare card for the patient).

I have read and understood the billing arrangements. *

SIGNATURE

I confirm that the above information is correct and accurate at the time of signing

Patient/ Guardian Signature (or printed name in full) *

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Date *

Printed Name

CONSENT - SHARING OF INFORMATION

Patient Name *

Patient D.O.B.

I agree to the sharing of relevant information between Red House Paediatrics and other members of my child's healthcare team, including but not limited to; General Practitioner, other treating Doctors/Specialists, allied health, hospitals, radiology and pathology providers.

I consent to Red House Paediatrics requesting, receiving and sharing information relating to my child's medical history, results and correspondence. Information may be requested and shared via email, fax, verbally or hard copy.

Patient/ Guardian Signature (or printed name in full) *

Draw signature|Type signatureClear

Date *

Printed Name *

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