New Patient Consent

New Patient Registration and Informed Financial Consent

Paper forms are available in Dr Handmer's office at the time of your appointment if you are unable to complete this electronic form for any reason.

PATIENT DETAILS

Please enter details exactly as recorded on your Medicare card

First Name *

Last Name *

Preferred Name (If applicable)

Date of Birth *

PATIENT CONTACT DETAILS

Mobile Phone

Home Phone

Email

Postal Address

Preferred contact method for us to contact you

PhoneEmailEither

EMERGENCY CONTACT DETAILS

Emergency Contact Name

Relation To You

Phone

REGULAR GENERAL PRACTITIONER

Regular GP's Name

Address and/or Phone

Other Doctors to Include in Letters (List if applicable)

MEDICARE

I have Medicare cover *

YesNo

Medicare Card No. *

Position on Card *

Expiry (eg 08/2029) *

Medicare Address (only if different to your residential address)

PRIVATE HEALTH INSURANCE

I am seeking treatment in: *

Private health system, including private hospitals if requiredPublic health system, including public hospitals if required

Private health insurance cover status *

I hold current private health insurance that covers hospitalisationI am unsure if my insurance covers hospitalisation / I am within 'wait' periods for a new policyI do not hold private health insurance

Health Fund Name

Membership No.

Expiry (if applicable)

DVA

I have DVA coverage *

YesNo

DVA No.

My DVA coverage includes the condition for which I have been referred

Yes, I have a DVA approval for this conditionI do not have DVA approval for this conditionI am unsure

REGARDING MY CLINICAL PROBLEM

I have seen another Urologist for this problem within the last year *

YesNo

If you have additional scans, documents or referrals, please upload them here (if your referral has already been sent to us, you do not need to re-attach it)

Browse

I have urinary symptoms / complaints

YesNo

Night time symptoms

NoneOnceTwice3 times4 times5 or more

7. Nocturia - Over the past month how many times did you most typically get up each night to urinate from the time you went to bed until the time you got up in the morning?

Quality of life

DelightedPleasedMostly satisfiedMixedMostly unhappyUnhappyTerrible

IPSS sum

INFORMED FINANCIAL CONSENT & SIGNATURE

I consent to the practice of Dr Marcus Handmer accessing, collecting and storing my information for the following purposes in accordance with applicable legislation:

1) Administrative - within this practice and associated facilities, including dictation /generative AI consult recording / scribing / secure documentation software

2) Billing, compliance, professional development, clinical audit and insurance

3) Disclosure to other health professionals involved in my past, present or future care including, MyHealthRecord where applicable

I understand that if my information is required for additional purposes my consent will be requested.

I understand that I may request a copy of my medical records subject to administrative fees excepting circumstances where access may be legitimately withheld.

I consent to claims being electronically lodged with my health fund and/or DVA/Medicare for my care and understand that I will be notified where possible ahead of time if any out of pocket ‘gap’ fees from this practice may apply to my treatment.

I am aware that this is not a 'Bulk Billing' private practice, and that fees may apply to consultations and/or hospitalisation.

I consent to clinical examination relevant to my health condition.

I confirm that above information I have provided is true, complete and accurate. *

Patient Signature *

Clear

Today's Date

This form is served from within Australia and is hosted with a service which complies with the Australian Privacy Principles

Phone: (02) 4001 0147 Fax: (02) 4913 5363

Email: info@urologysurgery.com.au

Office:42 Smith St, Charlestown, NSW 2290(Free patient parking on site at front and rear of building via central laneway)

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