Country of Birth
Language spoken at home
Are you a permanent resident of Australia?
Are you of Aboriginal descent?
Are you of Torres Strait Islander (TSI) descent?
Use street address?
Medicare Card No
(10 digit card number e.g. 1234567890)
(the number next to your name)
Pension Card No
DVA File Number
PRIVATE HEALTH INSURANCE DETAILS
Private Insurance Fund Name
No Health Fund
Australian Health Management
Australia Unity Health Limited
Level of cover if known
Hospital excess if known
Have you paid your excess this calendar year?
If No, the excess should be paid on the day of your procedure or admission. (We accept cash, EFTPOS/credit cards and bank cheques).
Do you have a General Practitioner?
NEXT OF KIN / EMERGENCY CONTACT
CARER DETAILS IF DIFFERENT TO NEXT OF KIN
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:
(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.
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