Partner Registration Partner Registration FormPatient Registration Registration Form PartnerName* DrMissMrMrsMsOtherRev. Title Given Name/s Last Date of Birth*Gender*FemaleMaleHome Address* Street Address Address Line 2 Suburb State Post Code Postal Address Street Address Address Line 2 Suburb State Post Code Email Home PhoneWork PhoneMobile PhoneOccupationNext of Kin/Guardian NameNext of Kin/Guardian Date of BirthNext of Kin/Guardian PhoneNext of Kin/Guardian RelationshipUsual General Practitioner NameGeneral Practitioner Address Street Address Address Line 2 Suburb State Post Code PhoneFaxMedicare NumberMedicare Card Reference NumberThe number you are listed as on the cardMedicare Card Expiry DatePrivate Health Fund NameIf applicablePrivate Health Fund NumberMedical History High blood pressure Diabetes High cholesterol Heart problems Stroke Cancer Asthma/Chest problems Kidney problems Liver problems Blood clots/Thrombosis Depression Stress/Anxiety Claustrophobia Smoking History Never smoked Ex-smoker Current smoker Alcohol Intake Non-drinker Rarely/Light Moderate Heavy HeightWeightConsentsUse of photography / Clinical images* I consent to the below I would like to discuss this further Toowoomba Obstetrics & Gynaecology (TOAG) at all times respect our patients' right to privacy, and informed consent for procedures within our practice, including photographic records. I understand and consent to the necessity of clinical images for medical records, preoperative and postoperative assessment, or advice on diagnosis, treatment, and management. I understand and approve the potential use of my photographs for medical research and/or patient education purposes. I understand and consent that my identity will be kept confidential; however, in some circumstances, some identifiable details may be displayed.Patient’s Health information* I consent to the below I would like to discuss this further Your health information is essential to ensure accurate and effective health care and service provision, this will be retained and exclusively used in the following ways. To diagnose your medical condition and provide a treatment where necessary. For administrative purposes in the operations of the practice. For communication or referral to other medical specialists, if required. For billing and collection purposes, including but not limited to compliance with Private health fund, Medicare and Health Insurance Commission requirements. De-identified information for research purposes (publication of clinical photographs or shared with your care partners). I consent to Toowoomba Obstetrics & Gynaecology, collecting my health information.General communication and contact* I consent to the below I would like to discuss this further I give TOAG and their staff permission to contact me by telephone and if necessary, leave a message. I permit Toowoomba Obstetrics & Gynaecology to provide me with documentation regarding the practice. I have read, understand, and approve all of the above information, and all my questions have been answered.Signature Consent* I acknowledge the e-signature By selecting the above box I acknowledge this replaces my signature as an e-signatureΔ
