Perth Women's Specialist Clinic - Patient Information

Patient Information Form

Your Details

Name must match Medicare card's name

Title

Given Name

Last Name

Street Address

Suburb

Postcode

DOB

Height

Weight

Marital Status

Current Occupation

Contact Details

Contact Phone No.

Work Phone No.

Mobile No.

E-mail Address

Emergency Contact Details/ Next of Kin (NOK)

Partner's Name

Partner's Contact No.

NOK's Name/ Relationship

NOK's Contact No.

Your GP

Referring Doctor

Your Usual GP's Name and Address (if different to above)

Medical Insurance

Medicare Number

Medicare Reference No. (alongside your name)

Medicare Expiry Date

Private Health Fund Name

Uninsured

Private Health Fund Membership Number

Medical Issues

Medical History (please list any medical problems you have)

Surgical History (please list any surgeries you have had in the past)

Obstetric History (please list any pregnancies including miscarriages, terminations to date in order); please include details of the pregnancy, i.e. the year, outcome of pregnancy, complications etc.

The result & year of last PAP smear/ HPV cervical screening test

Medications

Allergies

Smoking

YES NO

Alcohol

YES NO

Family History (please list any medical problems that run in the family)

How did you hear about Perth Women's Specialist Clinic

Please provide & complete the following :

Errors

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Privacy & Consent

The information we collect is used for the primary purpose of providing quality health care and may be utilized in the following ways:

Administrative purposes connected to the running of our medical practice.
Billing purposes, including compliance with Medicare and the Health Insurance Commission requirements.
Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you.

By submitting this form, I agree that:

I understand the reasons why my information must be collected.
I understand that I am not obliged to provide any information requested, but that failure to do so might compromise the quality of the health care and treatment given to me.
I am aware of my rights to access the information collected about me, except in some circumstances where access might legitimately be withheld and that an explanation will be given in this circumstance.
I understand that if my information is to be used for any purpose other than the above, my further consent will be obtained.
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 of which I may notify this practice.