PATIENT INFORMATION SHEET

Patient Details

Emergency Contact Information

Medicare - DVA

Hospital Private Health Fund (Must be GOLD Cover)

General Practitioner Details

Medical History

Consent

Please read this consent form carefully before signing.

Apollo Cardiology collects information from you for the primary purpose of providing quality health care.  Apollo Cardiology requires you to provide us with your personal details and full medical history so that we may accurately assess, diagnose and treat illnesses and medical conditions, ensuring we are proactive in your health care.  To enable ongoing care, and in keeping with the Privacy Act of 1988 and the Australian Privacy Principles, we wish to provide you with sufficient information on how your personal information may be used or disclosed and record your consent or restriction to this consent.

Your personal information will only be used for the purpose for which is was collected or as otherwise permitted by law, and we respect your right to determine how your information is used or disclosed.

The information we collect may be collected by a number of different methods and examples may include medical test results; notes from consultations, Medicare details, data collected from observations and conversations with you and details obtained from other health care providers.  

By signing below, you (as a patient/ parent/guardian) are consenting to the collection of your personal information, and that it may be used or disclosed by the practice for the following purposes:

  • Administrative purposes in running our medical practice.

  • Billing purposes, including compliance with Medicare requirements.

  • Follow up reminder and recall notices for preventative healthcare.

  • Disclosure to others involved in your health care, including treating doctors and other specialists outside this medical practice.  This may occur through referrals or for medical tests and in the reports or results returned to us for the referrals.

  • Accreditation and quality assurance activities to improve individual and community health care and practice management.

  • For legal related disclosure as required by a court of law.

  • For the purposes of research only where de-identified information is used.

  • To allow medical students and staff to participate in medical training/teaching using only de-identified information.

  • To comply with any legislative or regulatory requirements e.g., notifiable diseases.

  • For use when seeking treatment by other doctors in this practice.

At all times, Apollo Cardiology is required to ensure your details are treated with the utmost confidentiality.  Your records are very important, and we will take all steps necessary to ensure they remail Private and Confidential.

By signing below, you give permission for your personal information to be collected, used and disclosed as described above including contact via SMS to your mobile number and/or emails to the address you have provided.  You understand that only your relevant personal information will be provided to allow the above actions to be undertaken and that you are free to withdraw, alter and restrict your consent at any time by notifying the practice in writing. 

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