PATIENT INFORMATION FORM


PRIVATE HEALTH INSURANCE (IF APPLICABLE - IF NONE, SKIP)

GENERAL PRACTITIONER

NEXT OF KIN DETAILS

YOUR MEDICAL HISTORY

INFORMATION CONSENT

CONSENT :  I give my consent for doctors and staff to collect, use and disclose my personal information.  The purpose  for  collecting this  information  is  to  provide  quality  medical  and  health  related  services,  billing  and account keeping as required for practice management.  I am responsible for all my accounts.  I agree that my information will be managed in accordance with the National Privacy Act (1988).


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