• 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: 8 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
  • CONSENT TO COLLECT PATIENT INFORMATION

    Medical care requires full knowledge of patient health information by all members of a medical team. To ensure quality and continuity of patient care, a patient’s health information has to be shared with other health care providers and diagnostic facilities from time to time. Some information about patients is also provided to Medicare and private health funds (if relevant) for billing and medical rebate purposes.

    We will use the information you provide in the following ways:
    1. Administrative purposes in running our medical practice.
    2. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
    3. Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you.

    • I understand the reasons why my information must be collected.

    • I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me.

    • I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.

    • I understand that if my information is to be used for any purpose other than the above, my consent will be sought.

    • I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.

    • I consent to this practice obtaining medical reports, correspondence and histology from my other health care professionals to assist with a continuity of care if required.
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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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