Patient Registraion

Patient Registration Form

Patient Registration

Registration Form

  • The number you are listed as on the card
  • If applicable
  • If applicable
  • Consents

    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.
    Toowoomba Obstetrics & Gynaecology will retain your health information as part of your health service provision. Please read and consent to give approval for this information to be collected and stored. Your medical information will be used exclusively for providing health care in the following way: To diagnose your medical concern and provide a treatment where necessary; For administrative purposes in the operations of the practice. For communication of your health to other Doctors involved in the provision of healthcare, and the following confidentiality when storing reports and information provided to this practice by other medical specialists; and for billing and collection purposes, including but not limited to compliance with Private health fund, Medicare and Health Insurance Commission requirements. You may gain access to your health information by writing to us. If you do not consent to provide us with your health information, we may be unable to provide you with a health service. De-identified information may be used for research purposes. This may include the publication of clinical photographs in research publications and may be shared with your business support partners. The staff at Toowoomba Obstetrics & Gynaecology may need to contact you via phone or email, from time to time it may be necessary for their staff to leave a message, I understand this is a necessary part of contact in some cases.
    A pelvic ultrasound looks at the lower part of your abdomen with no risk or complications. A transvaginal ultrasound may be performed to obtain optimum images and assess the uterus and ovaries. It is not a compulsory process and requires your consent before undertaking. The transvaginal ultrasound will not be performed if you have never been sexually active. The transvaginal ultrasound consists of introducing the ultrasound transducer into the vagina, this can be done by yourself or the examiner. The transducer will be moved during the procedure to obtain optimum images, please advise if you experience any discomfort. It will take approximately 15 minutes and can be stopped at any time, upon your request. A third person can act as a chaperone, our receptionists can be of assistance if you require. Dr Homar will further explain this procedure in the consultation room, and you are welcome to discuss any concerns and ask as many questions as you need. I understand the Pelvic ultrasound procedure and its purpose, I give Dr Homar permission to perform the ultrasound. I am aware of my right to review my decision, even after signing this document.
    For TOAG promotional and marketing perspectives, both online and offline, photographs and/or videos of patients, their babies, and other family members may be used in social media platforms, Facebook, Instagram, YouTube, and our TOAG website. I acknowledge that I am the legal guardian and allow TOAG to use and display my photos/video taken or sent, as mentioned below by:
    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.
    By selecting the above box I acknowledge this replaces my signature as an e-signature
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