New Fertility Patient Partner Information Form

Thank you for filling out this patient information sheet. Please complete this form to the best of your ability. If you have any questions, please ask the reception staff. We need this information to provide you with the best quality care. The information on this sheet is kept private and secure as required by Federal, State and local Government privacy laws. Please notify us as soon as possible if there are any changes to your contact details. Accurate details not only help us identify you and your medical records, it also allows us to contact you promptly about tests, results, appointments, etc.

Your privacy is our concern. Dr James Orford and staff respect your right to privacy and acts in accordance with the National Privacy Act and the Australian Privacy Principles. All information collected in this practice is treated as sensitive information. Should you wish to read our privacy policy in full, a copy can be found on our website. If you would like a copy, please ask Dr Orford’s staff and they will be happy to give you one.

As well as the information collected on this patient information sheet, we may also collect the following:

• - Details of consultations you have with Dr Orford’s practice
• - Any additional information provided to us by your referring practitioners
• - Clinical photographs, ultrasounds, pathology or radiology results, etc

We will only use the information obtained from you to:

• - Assist Dr Orford and staff in providing services and care for you
• - Assist the practice with any internal administrative requirements, eg, billing, debt collection
• - Disclose selected information to other health services involved in supporting your health care management, eg, another Specialist, pathology, radiology, hospital, your referring practitioner, etc

We will not disclose your personal information to another person except when:

• - You have provided us with written consent
• - The use is for direct mailing in specific circumstances and where a person would reasonably expect such use or disclosure
• - It is required by Commonwealth or State legislation or in circumstances related to public interest or public or individual health and safety

You are entitled to have access to, and request the amendment of, personal information that Dr Orford’s practice has collected about you. This can ONLY be done by arranging an appointment with Dr Orford. Please speak with Dr Orford’s staff so they can organise this for you. A standard consultation fee will apply, however, this cannot be claimed back from Medicare or your health fund.

I give my consent to Dr James Orford’s Practice, or their agents and advisors, to contact medical practitioners, health care professionals or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners, health care professionals and/or other bodies to release such information, which may include sensitive health information, to Dr James Orford’s Practice or their agents and advisors, as may be requested. I understand that unless I advise otherwise, Dr James Orford’s Practice will continue to liaise with/contact medical practitioners, health care professionals or other bodies on matters related to my ongoing care.

Patient Acknowledgement - I acknowledge I have read the above information and understand the requirements of Dr James Orford’s Practice and myself in how to manage my personal information whilst attending Dr Orford’s Practice.