Patient Information Form

Patient Information Form

PATIENT DETAILS

First Name

Last Name

Preferred Name

Date of Birth

Gender

MaleFemale

English is a Second Language

YesNo

Do you require an interpreter? If So, which dialect?

PATIENT CONTACT DETAILS

Home Phone

Mobile Phone

Work Phone

Email

Address

Postcode

City / Suburb

State

NEXT OF KIN CONTACT DETAILS

Do you give permission for your Next Of Kin to be provided with your information (i.e. appointments?)

YesNo

Next of Kin - Name

Next of kin - Email

Next of kin Home Phone

Next of kin - Mobile Phone

Best way to contact your next of Kin

Home PhMobile PhWork Ph

REGULAR GP / INTERESTED PARTIES

GP Doctor’s Name

GP Practice name

Interested Party Doctor Name

Interested Party Practice Name

MEDICARE

Medicare First Name

Medicare Surname

Medicare Card No.

Reference No. (number next to your name)

Medicare Address (if different to your residential address)

PRIVATE HEALTH INSURANCE

Do you have Private Hospital Insurance Cover & have held your cover for more than 12 months?

YesNo

Health Fund Name

Membership No.

Level of Cover (Gold, Silver, Bronze)

PENSION / HCC/DVA Card

Do you have an aged pension card, healthcare card or a DVA card

YesNo

Card Type

HCCPension

Card No.

Expiry(mm/yyyy)

DVA No.

CONSENT TO COLLECT INFORMATION

In order for us to provide you with the best service possible, we need your consent to collect personal information. This practice collects personal information from you to adequately assess and treat you. We use your information according to the Privacy Act 1988 (Privacy Act). Your information is used in the following ways: Administrative purposes, billing and claiming to third parties such as Medicare and Private Health Funds, to other health providers involved with your care including treating doctors and specialists, radiology and pathology providers. If your personal information is required to be used in any other way than outlined above, your written consent will be obtained. By signing below, you acknowledge that you have read and understood the information provided above. You consent to your personal information being used within guidelines of the Privacy Act 1988. You understand that while you are not obliged to disclose your personal information, however failure to do so may compromise the quality of care you receive. *

Patient/Guardian Signature

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Date

CONSENT TO USE AI TRANSCRIPTION

Dr Floreani seeks your permission to use AI transcription technology – i-Scribe captures and transcribes conversations between you and Dr Floreani. Dr Floreani may have i-Scribe running in the background during your consultation. i.Scribe will listen to, and transcribe, your consultation. The transcribed notes will be reviewed and verified by Dr Floreani before being added to your medical record. All notes, letters, and transcriptions are securely stored and are only accessible to authorized personnel in this clinic, for a short period of time. The information captured by i-Scribe is treated with confidentiality in accordance with Australian Privacy Principles and the Privacy Act 1988. Your personal and medical information will not be shared with any unauthorised parties. You have the right to withdraw your consent at any time without affecting your ongoing care. By signing below, you acknowledge that you have read and understood the information provided above. You consent to the use of i-Scribe during your consultation and the transcription of your conversations being used for the purpose of medical documentation. *

Patient/ Guardian Signature

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