• Patient's Information

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  • Next of Kin

  • Correspondence with other medical practicitioners

    Are there other medical practitioners you would like correspondence to be sent to apart of your referring Dr and usual GP? If so, please list:
  • Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 2 MB.
    Allowed file types are .jpg, .png, .pdf, .doc or .docx. If your referral is a different format please email us at info@gastrohobart.com.au

    This specialist medical practice collects information for the purpose of providing quality and continuity for your health care. In keeping with the Privacy Act 1988 and Australian Privacy Principles, we wish to provide you with adequate information on how your personal information will be used or disclosed. Your personal details will only be used for the purposes for which it was collected or as otherwise permitted by law. The information we collect may be collected by different methods and examples may include: pathology/imaging results, consultation notes, Medicare/Private Health details, and details obtained from other health care providers.

    By signing below, you (as a patient/parent/guardian) are consenting to the collection of your personal information, and that it may be used or disclosed by the practice for the following purposes:

    • • Administrative purposes in running our specialist medical practice.
    • • Billing purposes, including compliance with Medicare requirements.
    • • Follow-up reminder/recall notices for treatment and preventative healthcare.
    • • Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals.
    • • For legal related disclosure as required by a court of law.
    • • For use when seeking treatment by other doctors in this practice.

    At all times, we are required to ensure your details are treated with the utmost confidentiality. Your records are very important and we will take all steps necessary to ensure they remain confidential.

    Please complete the form below if you understand and agree to the below statements in relation to our use, collection, privacy and disclosure of your patient information.

    I have read the information above and understand the reasons why my information must be collected, and the purposes for which my information may be used or disclosed. I understand that if my information is to be used for any purpose other than that set out above, my further consent will be obtained.

    I give my permission for my personal information to be collected, used and disclosed as described above including contact via SMS to my mobile phone number and/or email to the address I’ve provided. I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.

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  • Your privacy and the security of your data is important to us. We use an SSL (Secure Sockets Layer) certificate to make a secure connection between our website and your browser.

    After your form has been submitted a PDF of the content is generated and sent to our reception via our secure email platform. Immediately after the PDF is generated all parts of the form except the name of the patient are encrypted in our database and erased after 24 hours.

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