Ear gauge or split ear lobe registration

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Help us provide you with excellent care: Please read and complete this form

Do you have an existing appointment booked at our clinic?

yes

no, please contact me via phone to discuss

no, please email me with appointment options

no, I will contact your office

Appointment preferences

Preferred days

Monday

Tuesday

Thursday

No preference

Which days suit you? (select all that apply)

Preferred time of day

Morning (9am to 12pm)

Early afternoon (12pm to 2:30pm)

Late afternoon (2:30pm to 4:30pm)

No preference

Optional notes

Anything else we should know about your availability?

Patient information

Patient Name

Title Given name(s) Preferred name Surname

Date of Birth

Day

Month

Year

Home phone

Mobile phone

Occupation

Medicare number

Enter Medicare number (no spaces needed)

Medicare reference number

Please enter a number from 1 to 9.

Month

Medicare expiry month

Year

Medicare expiry year

Do you need an interpreter?

yes

What language interpreter do you require?

With adequate notice, we can organise a TIS Online video interpreter for eligible appointments. If you access an Auslan interpreter through NDIS funding, please continue to arrange this as you normally would.

Address

Street Address

Address Line 2 (optional)

Suburb

State

Postcode

Next of Kin

Next of Kin relationship

Next of Kin contact phone number

Referral information

General practitioner (if not your referring doctor)

General practitioner's address (if not your referring doctor)

Referral (if not already provided)

Drop files here or

Max. file size: 2 GB.

Please upload photographs of both ear lobes

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 2 GB.

Which ear lobe(s) do you wish to have treated(Required)

Both ear lobes

Right ear lobe only

Left ear lobe only

What is your desired outcome from surgical treatment?(Required)

Funding / Insurer

Funding type(Required)

Please select the insurance/rebate type applicable to you

Private health insurer

Membership number

Medical history

Allergies

List any known allergies

Medications

List any regular or commonly taken “as needed” medications

Medical conditions

Diabetes

Asthma or breathing issues

Smoker

Heart disease

On blood thinning medication

On GPL-1 medications (eg Ozempic)

Tick all that apply

Medical conditions

This allows you to provide more detailed important information about your general health

What happens next?

Once you submit this form, Dr Jill Tomlinson will carefully review the information you have provided to assess your condition and suitability for treatment.

Our administrative team will then send you a personalised fee estimate for your proposed care. This will typically include the cost of your procedure and standard follow-up.

After receiving your fee estimate, you can decide whether you would like to proceed with a telehealth consultation. This appointment allows Dr Tomlinson to confirm the treatment plan, answer your questions, and ensure appropriate planning before any procedure.

In some cases, if the information provided is incomplete or does not allow a clear procedure recommendation, you may instead be advised to attend a standard consultation rather than proceeding via the “See and Treat” service.

There is no obligation to proceed at any stage. If you choose to continue, our team will assist you in arranging suitable appointment times.

Consents and acknowledgements

Please read the following information carefully before proceeding. Your acknowledgements are required for us to provide your care.

Privacy & Collection of Health Information

Dr Jill Tomlinson collects personal and health information that is necessary to provide you with medical assessment, treatment, surgical care, and associated administrative services.

This information may include:

Your contact and identification details
Medicare, DVA, TAC, WorkCover or private health insurance information
Medical history, medications, allergies, and investigation results (including imaging and pathology)
Referrer details and clinical correspondence

Your information is collected directly from you where possible, and may also be obtained from your referring practitioner, other treating health professionals, hospitals, imaging or pathology providers, Medicare, DVA, insurers, or other third-party payers involved in your care.

Your information may be used and disclosed for the purposes of:

Providing medical assessment, treatment, and follow-up care
Communicating with your referring practitioner and other relevant health professionals
Arranging hospital admission and surgical care
Billing Medicare, DVA, TAC, WorkCover, private health insurers, or other third-party payers
Practice administration, accreditation, and quality assurance activities

Your information is stored securely and handled in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles.

Privacy Consent(Required)

I consent to the collection, use and disclosure of my personal and health information as described for the purposes of my medical care, coordination of care, and associated administrative and billing functions.

Financial Responsibility

Consultation fees are payable on the day of your appointment unless prior arrangements have been made.

You acknowledge and agree that:

Medicare rebates are set by Medicare and are not controlled by this practice.
Private health insurance rebates vary depending on your level of cover and insurer.
You are responsible for any gap fees, excess payments, or costs not covered by Medicare, DVA, TAC, WorkCover, or your private insurer.

If surgery is recommended, you will be provided with a written estimate outlining surgeon, assistant, anaesthetist, and hospital fees prior to proceeding.

Failure to attend a scheduled appointment without adequate notice may result in a cancellation fee in accordance with our cancellation policy.

Financial Responsibility Acknowledgement(Required)

I confirm that I have read and understood the Financial Responsibility information and agree to be responsible for all applicable fees, including any gap payments, and to comply with the practice’s payment and cancellation policies.

Assignment of Medicare, DVA and Insurer Benefits

Where applicable, you authorise Dr Jill Tomlinson to submit claims to Medicare, the Department of Veterans’ Affairs (DVA), TAC, WorkCover, or your private health insurer on your behalf for services provided.

You consent to the assignment of benefits payable for these services to Dr Jill Tomlinson, including for consultations and, where relevant, surgical procedures.

You acknowledge that you remain responsible for any fees not covered by Medicare, DVA, TAC, WorkCover, or your private health insurer.

Medicare / DVA / Insurer Assignment Consent(Required)

I authorise Dr Jill Tomlinson and her practice to submit claims to Medicare, DVA or relevant insurers on my behalf where applicable.

Electronic Communication

The practice may communicate with you via email or SMS regarding appointments, results, invoices, and clinical correspondence.

While reasonable steps are taken to protect your privacy, electronic communication carries inherent risks, including potential unauthorised access, delay, or non-delivery.

You are responsible for providing accurate contact details and notifying the practice of any changes.

Electronic Communicaiton Consent(Required)

I confirm that I have read and understood the Electronic Communication information and consent to being contacted by email and SMS for the purposes outlined.

Digital Documentation Assistance (Heidi Health)

Dr Jill Tomlinson uses a secure digital scribe system (Heidi Health) to assist with documenting consultations. This tool allows your clinician to focus on your care while accurately capturing clinical information.

Purpose

Heidi Health is used solely to create accurate and complete medical records. It supports your clinician but does not replace professional judgment; all medical decisions are made by your clinician.

How Your Data is Handled

Data is processed and stored in Australia in accordance with Australian privacy laws and the Privacy Act 1988 (Cth).
No audio recordings are stored. Conversations are transcribed in real time, and only the clinician-reviewed transcript is retained temporarily for inclusion in your medical record.
Your data is securely encrypted, access is strictly limited to your clinician, and regular audits are conducted to maintain compliance with global standards (SOC 2, ISO 27001).
Data is not used for secondary purposes, and identifiers are removed for any de-identified use.

Your Rights

You can choose to opt-out of using Heidi Health during your consultation at any time.
Withdrawing consent will not affect the quality of care you receive.
You have the right to access the information collected about you, except where access may be lawfully restricted.

More information about Heidi Health can be found at heidihealth.com.

Digital Documentation Assistance Consent(Required)

I confirm that I have read and understood the Digital Documentation Assistance (Heidi Health) information. I consent to the use of Heidi Health to assist my clinician with accurate documentation of my consultation, and I understand I may withdraw this consent at any time without affecting my care.

Clinical Photography

Clinical photographs may be taken as part of your care to assist with assessment, treatment planning, monitoring progress, and evaluating outcomes.

Photographs may also be used to communicate with other health professionals involved in your care, and in de-identified form for education or research.

All images are handled in accordance with the Privacy Act 1988 (Cth) and the Health Records Act 2001 (Vic). You may place restrictions on the use of your photographs.

Photography Acknowledgement(Required)

I confirm that I have read and understood the Clinical Photography information and consent to the taking and use of my clinical photographs, subject to any restrictions I specify below.

Restrictions on Use of Clinical Photographs

You may place restrictions on how your clinical photographs are used. If you choose to opt out of certain uses, you acknowledge that:

You have read and understood the information above regarding clinical photography.
You have received an explanation of why clinical photographs may be taken.
This practice has a privacy policy governing the handling of clinical images.
You are not obliged to consent to clinical photography; however, in some circumstances this may limit the assessment, treatment, or documentation that can be provided.
You have the right to access your information, except where access may be lawfully restricted, in which case an explanation will be provided.
Your photographs will not be used for purposes outside those described without your consent.

I wish to place restrictions on the use of my clinical photographs

Do not include photographs in my medical record as part of my treatment

Do not share photographs with other health professionals involved in my care

Do not use my photographs in de-identified form for education and training

Do not use my photographs in de-identified form in research publications (including journal articles or book chapters)

Do not use my photographs in de-identified form on practice websites for patient education

Do not use my photographs in de-identified form on practice social media for patient education