Contact Numbers
Please provide at least ONE number.
If you require any special consideration or assistance based on your cultural background please inform our staff when making your appointment.
By submitting this form, you give permission for the practice to contact you using the details provided for appointment reminders, clinical communications, general reminders, and the communication of test results.
Emergency Contact
This is compulsory.
To help us with your ongoing care, please complete your Usual Medical Practitioner details below
Allergy Information
Current Medications
Medical History
Lifestyle Risk Factor Information
Family Health History Information
If Applicable:
Health Information Collection and Use Consent Form
GP After Hours Mount Lawley is a private billing Practice.
WE DO NOT BULK BILL OR ISSUE ACCOUNTS.
- Payment is required at the end of the consult and we accept credit card, EFTPOS and cash. No cheques, Diners or Amex.
- Medicare will rebate you a portion of the fee. We can lodge this here only if you have provided Medicare with your bank details.
- Please note: there may be extra costs additional to your consultation, e.g. urine and blood testing, suturing, etc. Pathology and radiology costs are not generated from or associated with our practice.
- Important: GP After Hours Mount Lawley does not prescribe Schedule 8 drugs.
Your personal information will only be used for the purposes for which it 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 may include, but not limited to: medical test results, notes from consultations, Medicare details, data collected from observations and conversations with you, and details obtained from other health care providers (e.g. specialist correspondence).
By submitting this form, 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 the operation of our general practice.
- Billing purposes, including compliance with Medicare requirements.
- Follow-up reminder/recall notices for treatment and preventative healthcare, frequently issued by SMS.
- Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following 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 we are 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 remain confidential.
Please complete and submit this form only if you understand and agree to the following statements regarding the collection, use, privacy and disclosure of your patient information.
By submitting this form, you confirm that you have read the information above and understand why your information needs to be collected, and the purposes for which your information may be used or disclosed. You understand that if your information is to be used for any purpose other than those outlined above, your further consent will be obtained.
By submitting this form, you give permission for your personal information to be collected, used and disclosed as described above, including contact by SMS to the mobile phone number you have provided and/or by email to the email address you have provided. You understand that only relevant personal information will be provided where required to allow the above actions to be undertaken, and that you are free to withdraw, alter or restrict your consent at any time by notifying this practice in writing.
