New Patient Information Form

Thank you for filling out our patient information form. Please complete 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.

PATIENT DETAILS

Title

Surname (as shown on Medicare card)

Given Name (as shown on Medicare card)

Date Of Birth

Gender (optional)
FemaleMaleNon Binary

I use a different term:

Marital Status
SingleMarriedSeparatedDefactoDivorcedWidowed

Occupation (optional)

Home Address

Postal Address (if different to home address)

Home Telephone Number

Work Telephone Number

Mobile Phone Number

Preferred method of contact
HOME PHONEWORK PHONEMOBILE PHONEEMAIL

Medicare Card Number

Patient Ref Number

Expiry Date

Department Of Veterans Affairs (DVA) Card Number

Colour
GoldWhite

Expiry Date

Private Health Fund

Membership Number

NB - Have you been with your health fund for a minimum of 12 months as there may be waiting periods
for obstetric care? If not, please ensure to discuss the fees with our reception staff

Referring Practitioner's Name

Usual General Practitioner (if different to above)

If you would like other Healthcare Practitioner to receive copies of our correspondence, please list their details below

Emergency Contact Name

Relationship To You

Home Telephone Number

Work Telephone Number

Mobile Phone Number

Do you have any special needs, eg, limited mobility, sight or hearing which we need to know about?
YesNo

Do You Have An Advance Health Care Directive For End Of Life Care?
YesNo

Would you like a chaperone when you see Dr Orford? ( If yes, we will organise for a staff member to be present.)
YesNo

How did you hear about Dr Orford?

CULTURAL DETAILS

Australia is a genuinely multi-cultural society. Hence, knowing your cultural / religious details can help us provide health care that meets your individual needs.

If You Identify As Aboriginal And/Or Torres Strait Islander And/Or South Sea Islander And Wish To Have This Recorded, Please Indicate Below (optional):
AboriginalTorres Strait IslanderSouth Sea Islander

If You Wish To Self-Identify Your Cultural Background Please Specify Below (optional):

Country Of Birth

Is English Your First Language?
YesNo

If Not, Do You Require An Interpreter?
YesNo

If You Wish To Self Identify Your Religion, Please Specify Below (optional):

MEDICAL INFORMATION

List Current Medications (including prescription drugs, vitamins, etc)

List Dosage

Do You Have Any Allergies?(medications/foods/material)

Describe Reaction

Immunisation Status

Tobacco

I Have Never Smoked
Yes

I Ceased Smoking

I Currently Smoke

Alcohol
I Do Not Drink Alcohol
Yes

I Ceased Drinking

I Drink

Frequency
Per dayMonth

Recreation Drug Use

I Do Not Use Recreation Drugs
Yes

I Ceased Recreational Drugs

I Use

Have You Ever Had A Pap Smear? If Yes:

Date Of Last Pap Smear

Was It Normal?
YesNo

Your Approximate Height

Your Approximate Weight

If You Have Had Any Previous Pregnancies, Please Complete The Following
**M/A/E – Miscarriage, Abortion, Ectopic
[field_group pregnancy]

Date

Live
YesNo

M/A/E**

Weeks

Delivery

Comments

[/field_group]

Have You Been Diagnosed With Any Of The Following Conditions?

If You Selected Any Of The Above, Please Provide Details

Surgical History

[field_group Surgical]

Date Of Operation

Procedure

Findings

[/field_group]

I confirm the information I have provided is, to the best of my knowledge, accurate and there is no other information I am aware of which could influence the medical treatment/advice provided to me

Name (please print)

Signature

Date

PRIVACY ACT

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.

Consent To Release Of Information
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.

Consent To Release Of Information

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.

Please tick yes or no below to indicate if you give permission/consent for Dr James Orford’s Practice to:

Contact me via SMS regarding appointment detailsYesNo

Leave messages on my answering machine if necessary for my ongoing care, where information left will be to ask me to contact practice re appointment or results YesNo

Send me recalls and reminders via post if necessary to my ongoing careYesNo

Send me recalls and reminders via email if necessary to my ongoing careYesNo

Send me copies of invoices and bulk billing forms via email if necessaryYesNo

Participate in telephone/video consultations if necessary to my ongoing careYesNo

Keep photographs of me and/or my baby as part of my clinical recordYesNo

Contact my emergency contact when necessaryYesNo

Disclose my personal information toYesNo

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.

Name:

Signature:

Date: