To be completed by all new patients.

We are committed to providing our patients with the best care. To do this, it essential that your health record is kept up to date and accurate. All information is kept private and secure in line with our Privacy Policy.

Please complete the form below and click the SEND FORM button. If you need any assistance, please give us a call on (07) 3207 8222.

A. Demographic Information

Please provide at least one phone number

Next of Kin Details
Emergency Contact

(Someone we can contact if needed urgently)

Medicare Details
Veterans / DVA Card
Pension / Health / Seniors Cards

Reminder System - Our practice provides our patients with preventative care and early case detection reminders. e.g. immunisations, annual health checks, skin checks and pap smear.

B. Health History
Have any members of your family had...
Personal Health - Do you have a history of...
Social History
Adult Immunisations, have you had the following?...

Enter the date below if you have had immunisation. Leave blank if not. (MM/YYYY)

If completing this form for a child, are their immunisations up to date?


When did you last have the following...

Current Medication/Treatment

Please provide details of any current medication and treatments (including over the counter medications, vitamins, minerals, etc.)

We require your consent and personal information about you to use for reminder letters which may be sent to you regarding your health care and management.

Consent Form: Collection and Use of Health Information

Victoria Point Surgery, 1 Bunker Road, Victoria Point 4165
Phone: (07) 3207 8222 - Fax: (07) 3207 9333

As a patient of our medical practice we require you to provide us with your personal details and a full medical history, so that we may properly assess, diagnose, treat and be proactive I your health care needs.

We aim to protect the privacy and secure storage of your health information. You can request a copy of our privacy policy, which includes information about the collection, use and disclosure of your health information.

We require your consent to collect personal information about you and to use the information you provide in the following ways. Please read this consent form carefully, and sign where indicated below.

  • Administrative purposes in running our medical practice.
  • Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
  • Disclosure to others involved in your healthcare including treating doctors and specialists outside this medical practice. This may occur though referral to other doctors, or for medical tests and in the reports or results returned to us following referrals.
  • Disclosure to other doctors in the practice, locums etc. attached to the practice for the purpose of patient care and teaching.
  • For research and quality assurance activities to improve individual and community health care an practice management. Usually information that does not identify you is used but should information that will identify you be required you will be informed and given the opportunity to “opt out” of any involvement.
  • To comply with any legislative or regulatory requirements e.g. notifiable diseases.
  • For reminder letters which may be sent to you regarding your health care and management.

You can decline to have your health information used in all or some of the ways outlined above but it may influence our ability to manage your health care to provide the best outcome to you.

Please complete the following...
  • I have read the information above and understand the reasons why my information must be collected
  • I understand that I am not obliged to provide any information requested of me, but failure to do so may comprise the quality of 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 may be legitimately withheld. I will be given an explanation in these circumstances
  • I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained
  • I consent to the handing of my information be the practice for the purpose set out above, subject to any limitations on access or disclosure of which I notify this practice
  • The information I have provided is as accurate as possible
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