The Privacy Act 1998 gives you certain privacy rights in relation to the information you give this medical practice. We require your consent to collect personal information about you; your presence here suggests you consent to us knowing about your health situation for this presentation and holistic care. This form explains what your rights are over the use we make of the information supplied to us and how we disclose it to other medical service providers. We acknowledge the information we ask may be deeply personal; but not having this information will restrict our capacity to provide you with the standard of medical care you expect.Please READ the following information carefully and then sign where indicated below. This form will go on your file and you may examine or amend it at any time.

The Indillie Clinic collects information for the primary purpose of providing quality healthcare. We require your personal details and full medical history to enable a thorough and proper diagnosis and treatment of your medical condition/s. The information you provide will also be used in the following ways:

  • Administration purposes of this practice
  • Billing, including compliance with Medicare and Health Insurance Commission requirements.
  • Disclosure to others professionals involved with your healthcare,including those outside this practice. This may include referrals to other specialists, anaesthetists and pathologists.
  • Disclosure to others for medical defence purposes if necessary.
  • Disclosure to Locums when attached to this practice for the purpose of continuing patient care. Disclosure to Registrars in a de-identified form for specific or educational purposes. This includes photographic material and test results.

I have read this information and understand why collecting this information about me is necessary. I am also aware this practice has a privacy policy on handling patient information.

I understand that I am not obliged to provide any information required of me and I also understand that a failure to provide this medical practice with the information it requires may restrict the practice’s ability to provide the quality of healthcare and treatment.

I am aware that I have the right to access the information collected about me, except in certain circumstances, where access may legitimately be withheld. I understand I will be given an explanation in these circumstances.

I understand that if my information is to be used for any purposes other to what is set out above that my consent will be sought prior.

I do consent to the handling of my information by this practice for the purposes that are set out above, subject to any access of limitations or disclosure about which I will notify this practice now or in the future. I acknowledge that I have read this form prior to signing and any aspects of this form that I was unsure of were clarified by the practices staff.