Patient Registration Form Patient Registration Form Patient Registration Registration Form (2) Name* 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 Mobile PhoneHome PhoneWork PhoneOccupation Next of Kin/Guardian Name Next of Kin/Guardian Date of Birth Next of Kin/Guardian Phone Next of Kin/Guardian Relationship Usual General Practitioner Name General Practitioner Address Street Address Address Line 2 Suburb State Post Code Phone Fax Medicare Number Medicare Card Reference Number The number you are listed as on the cardMedicare Card Expiry Date Private Health Fund Name If applicablePrivate Health Fund Number Veterans' Affairs Card Number If applicableCard TypeN/AGoldWhiteMedical 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 Date of last pap smear Date of last mammogram Date of last menstrual period Height Weight ConsentsUse 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.Diagnostic Imaging Consent* I consent to the below I would like to discuss this further 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.Pathology/Histology Advice* I consent to the below I would like to discuss this further You may require pathology or histology to be completed by a pathology company e.g., blood tests, pap smears etc. The main company that we use is Sullivan and Nicholaides. Any testing requiring this service may incur a fee depending on the Medicare ruling. These tests are required as part of your healthcare plan with Toowoomba Obstetrics & Gynaecology to assist with your medical treatment and management. I understand that any third-party testing may incur an additional fee to my visit at the clinic.Media Consent* I grant permission to TOAG to use photographs/videos as outline above – using first names only I grant permission to TOAG to use photographs/videos as outline above - using NO NAMES I do not grant permission 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: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-signatureHow did you hear about Toowoomba Obstetrics and Gynaecology? Internet search Doctor/Specialist Website Social Media Previous Patient Family/Friend/ Colleague Other Δ
