QCG Patient Information Form

Please fill out all mandatory fields marked with an asterisk *

PERSONAL DETAILS

Title*

Given Names*

Surname*

Preferred Name

DOB*

Day

Month

Year

Sex*

Email*

Phone

Home

Work

Mobile*

What is your preferred method of contact for appointments/reminders?

SMS Phone

ADDRESS

Street Address

Address*

Suburb*

State*

Postcode*

Postal Address

Use street address?

Yes No

Address

Suburb

State

Postcode

MEMBERSHIPS

Medicare

Do you have Medicare?*

Yes No

Medicare Card No (10 digit card number e.g. 1234567890)

Reference No (the number next to your name)

Expiry Date (e.g. 01/2099)

Pension

Are you a pensioner?

Yes No

Pension Number (Old Age Pension only)

Expiry Date (e.g. 01/2099)

DVA

Are you a member of the Department of Veterans Affairs (DVA)?

Yes No

Veteran Affairs No

Expiry Date (e.g. 01/2099)

Card Colour

White Gold

Please ensure you have cardiac cover

If you require DVA transport, please let our staff know when booking all future appointments.

Private Health Insurance

Do you have Private Health Insurance?

Yes No

Private Insurance Fund Name

Please Specify

Membership Number

MEDICAL INFORMATION

Referring Doctor Name

Referring Doctor Phone

Referring Doctor Provider Number

GP Name (if different to Referring Dr)

GP Clinic

GP Name Provider Number

Allergies

Allergy	Reaction

Current Medications

Please enter your currently prescribed medications.

Drug Name	Dose	Frequency

Please enter any other additional medications.

INFORMATION DISCLOSURE

What number can we call you on regarding results/change an appointment?

Can we leave messages for you identifying the practice as the caller?

Yes No

I authorise the following person to take messages regarding a reminder / change of appointment / clinical details relating to my healthcare (if you do not nominate someone below, we will only be able to speak with you regarding the above)*

Name*

Relationship*

Phone*

NEXT OF KIN

Next of Kin:

Same as above

Name

Relationship

Phone

PATIENT SIGNATURE

Patient Signature*:
(Please use mouse or stylus to sign below.)

Privacy Act Consent Form

DETAILS

Queensland Cardiovascular Group is committed to protecting the privacy and security of any personal information it obtains about individuals and recognises that it must abide with the provisions of the Privacy Act 1988 (Cth).

We require your consent to collect personal information about you. Please read this form carefully, and sign where indicated below:

Queensland Cardiovascular Group collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways:

Administrative purposes in running our medical practice;
Billing purposes;
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;
Disclosure for research and quality assurance activities to improve individual and community health care and practice management;
Emergency situations whereby medical officers / hospitals require access to patient notes for treatment purposes.

If you have any questions about how we use the information you provide us, or if you would like to change your details, please call us on 07 3016 1111, email bookings@qcg.com.au, visit www.qcg.com.au and fill in the General Enquiry form, or write to Queensland Cardiovascular Group, PO Box 525, Spring Hill, QLD 4000.

I have read the information above and understand the reasons why my information must be collected. I am also aware that Queensland Cardiovascular Group has a Privacy Policy on handling patient information.

I understand that I am not obliged to provide any information requested of me, but 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 a reasonable explanation in these circumstances.

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 that I notify this practice of in writing.

PATIENT SIGNATURE

Patient Name:

Patient Signature:
(Please use mouse or stylus to sign below.)