Patient Form

The Privacy Act 1988 requires medical practitioners to obtain consent from their patients to collect, use and disclose that patient’s information. COLLECTION It is necessary to collect information to properly advise and treat you. We will obtain that information directly from you but may also obtain it from other doctors or allied health professionals involved in your care. USE & DISCLOSURE This information may be used and disclosed for a number of purposes including but not limited to: 1. Treatment of your condition 2. Referral to another doctor 3. Referral to a hospital 4. Account keeping and billing purposes 5. Quality Assurance 6. Research 7. Teaching Research and teaching purposes will not involve disclosure of any information that will allow personal identification. ACCESS You are entitled to access your own health records at any time convenient to both yourself and the practice. There are limited circumstances where access can be denied and it is asked that requests be in writing. There may be a small charge involved in providing that information. CONSENT I provide my consent for Dr Viswanathan to collect, use and disclose my personal information as outlined above. I understand that I may withdraw my consent as to use and disclosure of my personal information (except when legal obligations must be met). I understand that a more detailed policy regarding privacy is available upon request.

Accept terms Please read and click yes to accept terms: 1. Permission is given to release the medical history to the family doctor, insurance company. 2. Please be aware that any outstanding amounts requiring debt recovery will incur debt recovery fees and any legal costs involved: