New Patient Information Form

Thank you for filling out this form so that we have your details ready for your appointment with the Rheumatologist at ArthritisCARE. The information you provided will be securely sent to us and we will add it to your file for the doctor.

If you have any questions at all, please contact the Patient Support Team on email admin@arthritiscare.com.au or phone (07) 3255 1066.

Personal details

First Name *

Middle Name

Surname *

Preferred Name

Gender *

MaleFemaleNon-BinaryOther

Date of Birth *

Occupation *

Home Address *

Street address *

City *

State *

Postcode *

Postal Address (if relevant)

Your Preferred Phone Number for us to use *

Home Phone Number

Work Phone Number

Mobile Phone Number

Email *

Who is your usual GP?

Name of your usual GP *

Your usual GP's practice name and/or suburb *

Medicare Details

I am eligible to receive Medicare Benefits *

YesNo

Medicare Card Number (10 digits) *

Expiry Date listed on your Medicare Card *

Department of Veterans' Affairs

Are you a DVA Card Holder?

YesNo

My DVA Card type *

GoldWhiteOrangeOther (please provide details)

DVA Card Expiry Date *

DVA File Number *

Pension Details

Are you a Pensioner?

YesNo

If so, what type of Pension do you receive? *

Age PensionDisability Support PensionFull-time Carer's Pension

Pensioner Concession Card Number (Please note this does not include Health Care Cards or Commonwealth Seniors Cards) *

Pensioner Concession Card Expiry Date *

Private Health Insurance

I have Private Health Insurance

YesNo

Name of Health Fund *

Membership Number *

WorkCover

Is the cost of your consultation at ArthritisCARE approved for WorkCover?

YesNo

WorkCover Claim Number

Name of your Case Manager *

Your Case Manager's Phone Number

Your Case Manager's email

Any other contact details for your Case Manager

Any other health care providers you'd like to receive copies of your ArthritisCARE reports?

Name

Type of specialist or provider

Name of practice or suburb

Any test results or documents for your Rheumatologist to review?

Please upload any documents or test results related to your appointment

Browse

Emergency Contact

Name *

Relationship *

Preferred Phone *

Email address

Collection, Use and Disclosure of your Personal Information

ArthritisCARE respects your Personal Information, including your Health Information, which is Sensitive Personal Information under the Privacy Act 1988 (Cth). This document provides a brief summary of how we collect, use, hold and disclose your Personal Information.

We collect your Personal Information from all of the documentation and information provided to us, including but not limited to, your medical records, treatment plans, billing and insurance details. The types of information that ArthritisCARE collects and records may include personal contact details and Health Information such as the problem for which you seek treatment, the treatment advice provided and the results of any medical investigations or tests.

Your Personal Information may be stored electronically or in physical form and will only be accessed by authorised personnel at ArthritisCARE.

We may use your Personal Information:

To provide medical care and treatment to you
To update and keep current your medical records as required by our policies and law
To undertake billing activities, including liaising with private health fund insurers
To comply with legislative and regulatory requirements, including but not limited to those relating to the Medicare Australia Act 1973 (Cth) and the Health Insurance Act 1973 (Cth)
For necessary and related ancillary purposes

We may disclose your Personal Information:

To medical practitioners, other hospitals or health service providers involved in your treatment or care
To Medicare, your private health fund or other organisations directly relevant to your care (e.g. Department of Veterans’ Affairs or WorkCover)
To your nominated Emergency Contact Person
In an emergency where your life is at risk
To other third parties as may be required by law

If you have any questions about how we use your information, our Practice Manager will be happy to assist you.

Consent

I acknowledge that I have read and understood the summary of information in this document and that I consent to the collection, use, storage and disclosure of my Personal Information as detailed above *

YesNo

Permission to communicate with you by email

I give permission for ArthritisCARE to communicate with me via email, including sending of documents which may contain personal or medical information. I understand that the security of information sent via email cannot be guaranteed. *

YesNo

Permission to communicate with you by text messaging (SMS)

I give permission for ArthritisCARE to communicate with me via text messaging (SMS) sending messages which may contain personal or medical information. I understand that the security of information sent via SMS cannot be guaranteed. *

YesNo

Full name *

Signature *

Draw signature|Type signatureClear

Date *

Verification please *