NEW PATIENT DETAILS ON-LINE FORM - Crows Nest Eye Surgery

CROWS NEST EYE SURGERY - NEW PATIENT DETAILS

Mr/Mrs/Ms/Dr

Name:

First Last

Date of Birth:

Mobile Phone:

Home Phone:

Email:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

MEDICARE CARD No:

Number next to Name:

Valid To:

Private Health Fund:

Member Number:

Cover:

DVA/Veterans Number:

Type of Card:

Age-Pension Card Number: (Not Seniors or other Centrelink Card)

Usual GP/Last GP Seen:

Suburb:

Usual OPTOMETRIST/Where Glasses Made:

Suburb:

Emergency Contact/Next of Kin:

Phone:

Relationship:

NOTE: You may require drops in your eyes to dilate your pupils. These drops make your vision blurry for 90 minutes after you leave. Do not drive until after 90 minutes, or if you still feel your eyes are blurry. Ideally, use public transport or have someone else take you home.

MY HEALTH RECORD: My Health Record is an online summary of your key health information. You can access and control your My Health Record through your MyGov account. It you have not opted out, this practice may access your My Health Record to view information relevant to your medical care, and may also upload details of your care to My Health Record. Please inform the receptionist if you do not want your My Health Record to be accessed, or speak to Dr Chowdhury during your consultation.

PRIVACY STATEMENT: We require you to provide us with your personal details and medical history so that we may properly assess, diagnose and treat you with regard to your health care needs. We use this information for administrative and clinical purposes, and also disclose this information in a Letter to others involved in your care, including your GP, Optometrist and Other Specialists outside this medical practice. I understand the reasons why my information must be collected and consent to the handling of my information for the purposes above, subject to any limitations on access or disclosure of which I may notify this practice.