New Patient – Access Vascular

Name *

First

Last

Address

Address Line 1

City

State / Province / Region

Postal Code

Date of Birth

Home Phone

Work Phone

Mobile

Medicare Number

Expiry

Pension Card #

Private Health

Member Number

Dept. Veteran Affairs #

Dep Affairs #

White
Gold

General Practitioner

Medical Centre

Interested Parties

Next of Kin

Phone

Medical History Questions

Do you have Hypertension? (High blood pressure)

Do you have Ischeamic Heart Disease

Do you have Diabetes?

Do you have Chronic Heart Failure?

Approximate Height (cm)

Approximate Weight (kilos)

Have you ever had DVT? If yes, please provide details

Have you ever had a Pulmonary Embolism? If yes, please provide details

Do you have a history of any Vascular Surgery? If yes, please provide details

Do you take Aspirin, Plavix or any Anticoagulants (Blood thinners)? If yes, please provide details

Do you take any other medications? If yes, please provide details

Do you have any other diseases?

Patient Consent to Collect and Disclose Information

The Privacy Act of 1988 requires all health practioners to obtain consent from their patients to collect, use and disclose patients’ information.

Collection

Access Cardiology staff will collect information that is necessary for your treatment such necessary information may include:

Full medical and psychological history.
Family medical and psychological history.
Ethnicity.
Medicare / Private health fund details.
Billing and accounting information.
Contact Details.

The information will normally be collected directly from you; however, there may be occasions when it will be necessary to collect information from other sources with your prior consent. These sources may include but are not limited to:

Parents about children.
Children about their family.
Schools and teachers.
Other health care providers.

In emergency situations we may have to collect information from relatives or other sources without your prior consent.

Use and Disclosure

With your consent we will use and disclose your information for purposes such as:

Account keeping and billing.
To reply to your referring doctor.
Referral to another health care provide or hospital.
Management of access cardiology including quality assurance, practice accreditations and complaint handing.
To prevent or lessen a serious threat to an individual’s life, health or safety.
Where legally required to do so e.g. by a court, mandatory reporting etc.
To meet our obligations of notification to medical defense organisations or insurer.

Access

You are entitled to have access to your own health records at any time convenient to all parties. Depending on the nature of the access requested a charge might be payable where the practice incurs costs in providing access. There are some circumstances in which access may be denied, but in such an event you will be advised of the reason. If you find any information we hold on you is inaccurate or incomplete, please advise us so that we can adjust your record. We are not able to erase the original record.

Signature

Date