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Patient Information Form

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Patient Information and Registration Form

Step 1 of 4 - Personal Details

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Title*
Family Name*
First Name*
Address*
Street Address Address Line 2 City State / Province / Region Postcode
Date of Birth*
Date Format: DD slash MM slash YYYY
Email*
Home Phone*
Work Phone
Mobile Phone
Do you agree to have appointment reminders sent to you via SMS to your mobile?*
- Yes
- No
Are you on blood thinning medication?*
- Yes
- No
Are you Diabetic?*
- Yes
- No
IF YES: Do you take insulin?*
- Yes
- No
Allergies*
How did you hear of us?*
My Health Record*
I understand that NIPM has access to upload and view my ‘My Health Record’ unless I expressed they don’t.
- Yes
- No

Referring Doctor*
Type*
- Specialist
- GP Referral
Address*
Street Address Address Line 2 City State / Province / Region
Regular GP Name (if different to above)
Medicare Number
Family Number
Expiry Date
Are you in a health fund?*
- Yes
- No
Name of Health Fund*
Membership Number
Do you have a Pension Card?*
- Yes
- No
Pension Card Number*
Expiry Date*
Pension Type*
Do you have a Health Care Card?*
- Yes
- No
Health Care Card Number*
Expiry Date*
Do you have a Veterans Affairs Card?*
- Yes
- No
Veterans Affairs Card Number*
Expiry date*
Type*
- Gold
- Orange
- White
Is this a workers compensation/CTP claim?*
- Yes
- No
Employers Name*
Insurance Company*
Claim Number*
Case Manager*
Case Manager Phone*
Nominated Treating Doctor (if applicable)*
Suburb*

I give my permission for NIPM to communicate with the following persons regarding my appointments and/or treatment (e.g. Spouse, Parents, Children, etc.);
- Yes
- No
Next of Kin 1
Name
Relationship
Contact Number
Next of Kin 2
Name
Relationship
Contact Number

Release Name
*
- I authorise Dr Simon Tame, Dr John Prickett, Dr Harsher Kadavil and Christie Mason to release or obtain medical information to or from the referring doctor, general practitioner, insurance company, solicitor or other health professionals in matters concerning my health
Date*
Date Format: DD slash MM slash YYYY
If you are a signing on behalf of the patient;
Name
Relationship
Contact Number
As you will be a patient of our practice, we require you to provide us with your personal details. We may also need to collect and store information about you, so that we may properly assess, diagnose and treat your health care needs. Information may be collected and stored in paper, electronically or both. We aim to protect the privacy of your health information. We require your consent to collect your personal information, and for its use in the following ways:
- Administrative purposes.
- Billing purposes (including compliance with Medicare and Health Insurance Commission requirements).
- Disclosure to others involved in your healthcare. This includes your treating doctor and specialists outside this practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following referrals.
- Disclosure to other doctors in this practice for the purpose of patient care and teaching.
- Disclosure to your solicitor, insurance company and other health professionals in matters concerning your health.
- For research and quality assurance activities to improve individual and community health care and practice management. Only information that does not identify you is used in these circumstances.
- To comply with any legislative or regulatory requirements, such as notifiable diseases, and where we are compelled by law.
- For reminders and recalls which may be sent to you regarding your health care and management.
You can decline to have your health information used in all or some of the ways outlined above but it may influence our ability to manage your health care to provide the best outcome for you.
No 1
- I have read the information above and understand the reasons why my information must be collected.
No 2
- I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the quality of health care and treatment given to me.
No 3
- I am aware of my rights to access the information collected about me, except in some circumstances where access may be legitimately withheld. I will be given an explanation in these circumstances.
No 4
- I understand that if my information is to be used for any other purposes other than set out above, my further consent will be obtained.
No 5
- I consent to the handling of my information by the practice for the purpose set out above, subject to any limitations on access or disclosure of which I notify this practice.
No 5*
- I understand that My Health Record will be used at this practice, if required, to access my record and sometimes to upload information. Your permission to do so is automatic (per the My Health Records Act 2012), unless you express otherwise.
OR
Or
- I am unsure and would like to discuss this further with someone from the practice before I sign.
Patient Name*
Date*
Date Format: MM slash DD slash YYYY
Patient/Guardian Signature*
Name of Guardian (if applicable)
Name
This field is for validation purposes and should be left unchanged.

ABOUT US

At NIPM we treat all kinds of pain – and all aspects of living with chronic pain.

Main Practice Location
Suite 3, 20 Smith Street, Charlestown
NSW 2290
Tel.: (02) 4923 8900
Fax: (02) 4947 8991

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