Ear tag excision infant registration form

Title

Given name(s)

Preferred name

Surname

Date of birth

Address

Suburb

Postcode

Parent 1 full name

Medicare number

We have not received our baby's Medicare number yet

Medicare number

Medicare reference number

Expiry date

Parent 1 email

Mobile number

Home phone

tick here to opt out of SMS appointment notifications

Parent 2 full name

Parent 2 email

General practitioner (if not referring doctor)

General practitioner address (if not referring doctor)

Referral

If you have any other concerns about your baby's health let us know here:

Ear tag photographs

We require your consent to collect personal information about your child. Our practice collects information from you for the primary purpose of providing quality health care to your child. We require you to provide us with personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your child's health care needs. We will use your child's medical records: 1. In your medical treatment. This may include disclosure to individuals who are directly involved in your child's health care such as your child's General Practitioner, other treating doctors and any third party that is appropriately involved with your child's care. If we refer your child to another healthcare professional we will disclose relevant information to them about your child's personal details and health. 2. To conduct practice audit and medical research. In this case all data is analysed without including your identifying personal details. Audit and research are important in maintaining high standards of medical practice. Audit of surgical practice is a requirement of the Royal Australasian College of Surgeons. 3. To meet a legal requirement – for instance, if we are issued with a subpoena or summons. Our practice fully complies with the Privacy Act 1988 (Cth), the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth), the Health Records Act 2001 (Vic) and the My Heath Records Act (2012).

Privacy consent

Parent/guardian declaration As a parent/guardian of a patient of Dr Jill Tomlinson or her practice, I acknowledge that: - I have read the information above and understand why my child's information must be collected. I am also aware that this practice has a privacy policy on handling patient information; - I understand that I am not obliged to provide any information requested of me but that my failure to do so may compromise the quality of the health care and treatment provided to my child; - I am aware of my right to access the information collected about my child, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in such circumstances; - If my child has a My Health Record, it may be accessed during my treatment and information may be uploaded to My Health Record by registered healthcare practitioners at the practice; - I understand that if my child's information is to be used for any other purpose other than set out above, my further consent will be obtained; - I consent to the handling of my child's information by this practice for the purposes set out above, subject to any limitations on the access or disclosure that I notify this practice of; - I may request access to my child's personal information, which may be granted in accordance with the practice’s Access to Personal Information Policy. I will be provided with a written reason if access is denied; - I may request an amendment to my child's personal information if it is incorrect. I will be provided with a written reason if a request for amendment is denied; - My child's personal information will not be used for direct marketing or disclosed to overseas recipients; - I have the right to lodge a complaint about the handling of my child's personal information if I am dissatisfied, which will be dealt with in accordance with the practice’s complaint handling procedure.

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

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 me. - 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. - I consent to the use of my child's clinical photographs for the purposes set out above, subject to any limitations on the access or disclosure that I notify this practice of.

Payment terms

You will be asked to pay for your child's consultation on the day of service. EFT, EFTPOS, Visa and Mastercard credit facilities are available. Accounts that are not paid on the day of service will incur a 10% administrative surcharge.