General Registration Form

Title

Given name(s)

Preferred name

Surname

Date of birth

Medicare number

Medicare reference number

Expiry date

Mobile number

Home phone

Address

Suburb

State

Postcode

Occupation

General practitioner (if not referring doctor)

General practitioner address (if not referring doctor)

Referral

If not clearly specified in your referral, what is the reason you are seeking an appointment?

Funding type

Private health insurer

Membership number

extras

If Workcover, your employer

Employer's contact number

Workcover or TAC Claim number

Claims manager's email address

Date of injury

Workcover insurer (agent)

If DVA, Gold/White card number

Medical conditions

Medications

Allergies

Information Uploads

Please upload any supporting information that may assist Dr Tomlinson in the analysis of your health condition, such as radiology reports (x-ray, ultrasound, CT, MRI), nerve conduction studies, or photographs of the relevant area if there is a visible abnormality.

Imaging or nerve conduction study reports

Photographs of lesion/lump/injury/area of concern

Privacy & Financial Consent

Please read the following information carefully before proceeding. Your acknowledgement is required in order for us to provide care.

Privacy & Collection of Health Information

Melbourne Hand Surgery collects personal and health information that is necessary to provide you with medical assessment, treatment, surgical care, and administrative services.

This information may include:

- Your contact and identification details
- Medicare, DVA or private health fund information
- Medical history, medications, allergies and imaging
- Referrer details and correspondence

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

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

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

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

Privacy consent

I consent to the collection, use and disclosure of my personal and health information as described above for the purposes of my medical care and associated administration.

Financial Responsibility

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

You acknowledge that:

- Medicare rebates are determined by Medicare and are not controlled by the practice.

- Private health insurance rebates vary depending on your level of cover.

- 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 receive a written estimate outlining surgeon, assistant, anaesthetic and hospital fees before proceeding.

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

Financial consent

I acknowledge financial responsibility for fees associated with my care and understand that rebates and coverage are determined by Medicare, DVA and/or my private insurer.

Assignment of Medicare or DVA Benefits

Where applicable, you authorise Melbourne Hand Surgery to submit claims to Medicare, DVA or relevant third-party payers on your behalf and to receive benefits payable for services provided.This authority applies to consultations and, where relevant, surgical services.

I authorise the 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 privacy, electronic communication carries some inherent risks.

Electronic communication consent

I consent to receiving appointment reminders and clinical communication via email and/or SMS.

Digital Documentation Assistance

Dr Tomlinson uses a secure digital scribe system to assist with documentation and preparation of correspondence. This system generates a temporary written transcript of the consultation, which is reviewed and edited before inclusion in the medical record. No audio recording is stored, and transcripts are retained temporarily only.

Digital Scribe Acknowledgement

I acknowledge that a digital documentation assistant may be used during my consultation and understand I may decline this at any time.

Photographs can be valuable in assessment, tracking progress and recovery, evaluating the effects of treatment and the passage of time, communicating with other health care professionals who are involved in your treatment, and in education and research. Our practice fully complies with the Privacy Act 1988 (Cth) and the Health Records Act 2001 (Vic) and we offer all our patients the opportunity to place restrictions on the use of these images.

Photography consent

I acknowledge that I can place restrictions on the use of my photographs

I wish to place restrictions on the following potential uses of my child's clinical photographs. In opting out I acknowledge that: - I have read the information above and have received an explanation about what clinical photographs will be taken and why. - I am aware that this practice has a privacy policy on handling clinical photographs. - I am not obliged to agree to clinical photography as part of my child's treatment but that in some circumstances my failure to do so may compromise the quality, nature or circumstances of the treatment that can be provided to my child. - I am aware of my right to access the information collected about my child, except in circumstances where access might legitimately be withheld. I understand I will be given an explanation in such circumstances. - I understand that my child's photographs will not be used for any purpose other than set out above without my consent.

do not place images in my medical record as part of my treatment do not send to another health practitioner who is treating me do not use my images in de-identified form by health professionals for education and training do not use my images in de-identified form in research publications, including but not limited to journal articles and book chapters do not use my images in de-identified form on the http://jilltomlinson.com website for the purpose of patient education do not use my images in de-identified form on the practice Facebook Page for the purpose of patient or parent education