Busby Medical Practice - Patient Services Portal

New Patient Registration Form

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Personal Details

Title

 
 

First Name

 
 

Middle Names

 
 
 

Surname

 
 

Preferred Name

 
 
 

Date of Birth

 

Gender

 
 

Address

 
 

Phone Home

 
 
 

Phone Work

 
 
 

Email Address

 
 
 

Mobile Phone

 
 
 

Marital Status

 
 

Do you wish to identify as

 
 

Country of Birth

 
 
 

Other Cultural Background

 
 
 

Medicare Details

Medicare Number

 
 
 

Position on Card

 
 
 

Expiry Date

 
 
 

Health Care Card Details

Health Care/Pension Card number

 
 
 

Expiry Date

 
 
 

Veteran Affairs Number

 
 
 

Expiry Date

 
 
 

Your personal eHealth record

Have you registered to participate in the Personally Controlled eHealth Record System (PCEHR)

 
 

Emergency Contact Details

Emergency Contact: If possible, please nominate someone who lives local and can assist you in an emergency.

Full Name

 
 

Relationship

 

Address

 
 

Phone Home

 
 
 

Phone Work

 
 
 

Phone Mobile

 
 
 

Third Party

If you are not the person represented above, please type your name and relationship to the patient below

Your Name

 
 
 

Your Relationship to the patient

 
 
 

Important Information
Patient Health Information

In attending appointments at Busby Medical Practice, I (the patient), consent to the collecting of necessary health information by the Practice for the primary purpose of providing quality health care. This information may be used for:

  • Administrative purposes in running the Practice.
  • Billing purposes, including compliance with Medicare Australia requirements
  • Disclosure to others involved in your health care, including treating doctors and specialists outside this Practice.
  • This may occur through referral to other Doctors or the medical tests and in the reports or results returned to us
  • following referrals.
  • To contact you for the purposes of recalls, reminders, health and Practice information. I understand I can opt out of
  • this if I wish.
  • In-house teaching, Practice Accreditation and provision of information technology.
  • Research purposes having all identifiers removed to maintain anonymity.

I understand:
  • all Practice staff have signed confidentiality agreements as they may need to handle my medical information from time to time
  • the Practice holds personal information securely, whether it be in electronic or hard copy format.
  • the Practice will not disclose personal information to anyone outside Australia without need and without patient consent.
  • the exceptions to disclose without patient consent are where the information is:
    • Required by law
    • Necessary to lessen or prevent a serious threat to a patient's life, health or safety or public health or safety,
    • or it is impractical to obtain the patient's consent
    • To assist in locating a missing person
    • To establish, exercise or defend an equitable claim
    • For the purpose of a confidential dispute resolution process
  • access to my medical record requires a written request and an appointment with a Doctor.
  • a copy of my medical record to another clinic or personally may incur a fee. The request for the medical history will
  • not be processed until any outstanding accounts are paid in full.
  • Payment for each consultation must be on the same day as visit


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