New Patient Form

You can also download the new patient form and send it to us via email, fax, or HealthLink (ID: astrides).

Name(Required)

First Last

Date of Birth(Required)

Address

Street Address Suburb State Postcode Country

Contact Number (Home)

Contact Number (Mobile)

Email Address

I give consent for the practice and doctor to communicate with me by e-mail, including attachments of letters and results(Required)

Yes

Occupation

Marital Status

Medicare Number

Ref

Expiry

Pensioner Number

Expiry

DVA (Vet Affairs) Number

Circle

Gold

White

Private Health Fund

Membership Number

Do you have hospital cover with your private health insurance?

Yes

Usual GP (if different from the referring Doctor)

GP Contact Details

Emergency/ Next of Kin Contact — Name

Phone Number

Email Address

Relationship To You

Patient Consent & Privacy Act

The Privacy Act of 1988 requires medical practitioners to obtain patient consent to collect, use and disclose their personal information. The practice staff and medical practitioners may participate in the collection of information required to treat and advise you. This includes: Full medical history, family medical history, ethnicity, genetic information, contact details; Medicare/private health fund, billing and account details, information obtained from other sources, for example, (1) Other doctors (current or former), allied health professionals, dentists, hospitals and day surgery units, or (2) Relatives or other sources, in emergency situations where we cannot obtain your prior express consent.

Financial Consent

Autumn Strides operates as a private billing practice. All consultation invoices are to be paid on day of appointment and can be sent to Medicare for rebates.

Consent

I provide my consent for Dr Sneha Bharadwaj to collect, use and disclose my personal information as outlined above.
I understand that I am entitled to access my own health records except where access would be denied as outlined above.
I authorise the disclosure of all past and present protected health information requested by Dr Sneha Bharadwaj from health care professionals, hospitals or organisations.
I understand that I may withdraw my consent as to use and disclosure of my personal information (except when legal obligations must be met).
I understand the fee structure and agree that I am responsible for full payment of account fees, on the day of the consultation or prior to the consultation.

By ticking this box and typing your name below, you acknowledge and agree that this typed name will serve as your digital signature and carry the same legal weight and implications as a handwritten signature.(Required)

I consent

Name (First and Last)(Required)

Today's Date(Required)