CQRASC New Patient Registration Form – CQ Respiratory Diagnostics

"*" indicates required fields

Contact Details

Title

Name*

Middle Name*

Preferred Name*

D.O.B*

Gender*

Ethnicity*

Mobile Phone*

Home Phone

Work Phone

Email*

Address

Residential Address

Address

Street 1 Suburb State Postcode

Postal Address (If not same as Residential Address)

Address

PO Box

Health Fund & Insurance

Medicare Number*

Ref*

Regular Gp*

Private Health Fund*

Fund Number*

DVA Card Holder*

YES

Card Type*

DVA Number*

Exp*

Health Care Card or/and Pensioner Card Holder (Please circle concession card)*

Card Number*

Exp*

Next Of Kin

Name*

Phone*

Relationship

Emergency Contact

Name*

Phone*

Relationship

I clarify that the above information is true and correct. I authorise the use of my personal information as detailed in the Privacy Act clause. I have read and understand the TERMS AND CONDITIONS OF TRADE of Dr Sudhakar Koduri which form part of, and are intended to be read in conjunction with this Confidential Patient Account Information Form and agree to be bound by these conditions.

The medical information collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and full medical history so that we may properly assist, diagnose, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways: Administrative purposes in running our medical practice; Billing purposes, including compliance with Medicare and Health Insurance Commission requirements; Disclosure to others involved in your health care; Disclosure to other doctors in the practice including our reception staff; We are involved in Research Studies, which involve collating medical information for the purposes of auditing and quality assurance. All personal details involved in research and quality assurance are deleted and therefore you will remain anonymous; Emergency situations where medical officers/hospitals require access to patient notes for treatment purposes.

Signature*

Name*

Date*