PATIENT PROFILE

Title

Firstname

Lastname

Sex

DOB

Phone

Home

Work

Mobile

Occupation

Marital

Country of Birth

Language spoken at home

Are you a permanent resident of Australia?

Yes No

Are you of Aboriginal descent?

Yes No

Are you of Torres Strait Islander (TSI) descent?

Yes No

Street Address

Address

Suburb

State

Postcode

Postal Address

Use street address?

Yes No

Address

Suburb

State

Postcode

ENTITLEMENTS

Medicare

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

Expiry Date (e.g. 01/2099)

Reference No (the number next to your name)

Pension Card

Pension Card No

Expiry Date (e.g. 01/2099)

DVA

DVA File Number

Expiry Date (e.g. 01/2099)

Card Colour

White Gold

PRIVATE HEALTH INSURANCE DETAILS

Private Insurance Fund Name

Please Specify

Membership Number

Level of cover if known

Hospital excess if known

Have you paid your excess this calendar year?

Yes No

If No, the excess should be paid on the day of your procedure or admission. (We accept cash, EFTPOS/credit cards and bank cheques).

GENERAL PRACTITIONER

Do you have a General Practitioner?

Yes No

Name

Phone

Address

Postcode

NEXT OF KIN / EMERGENCY CONTACT

Name

Phone

Address

Relationship

CARER DETAILS IF DIFFERENT TO NEXT OF KIN

Name

Phone

Home

Mobile

ABOUT YOUR PERSONAL HEALTH INFORMATION

We acknowledge our obligations to you under the Privacy Amendment (Private Sector) Act 2000 and the Health Records and Information Privacy Act 2002. Personal health information we collect from you will be used primarily to ensure that you receive optimal care but may also be used for other purposes. Personal health information is released under legislation to the State Health Authority, health funds and the Private Hospital Data Bureau.

PERSONAL DETAILS CONSENT

I hereby consent to the collection and use of my personal health information for the purpose of my care and wellbeing and in accordance with the reporting requirements under legisations:

Patient Patient Representative

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

Relationship to patient

Marketing & Fundraising: Several times a year The Skin Hospital sends out newsletters and provides updates on fundraising activities. If you do not wish to receive these marketing communications please tick the box. Please note that only your name, address and email will be used for this, all other personal details remain confidential. The Skin Hospital does not share these lists with any other organisation.