See and treat application form

Title

Given name(s)

Preferred name

Surname

Date of birth

Medicare number

Medicare reference number

Expiry date

Mobile number

Home phone

Opt out

do not send me SMS appointment reminders

Address

Suburb

Postcode

Occupation

General practitioner (if not referring doctor)

General practitioner address (if not referring doctor)

Referral

To progress a See and Treat request we need you to describe specifically what you are wishing to have performed. For example, "I wish to have three prominent moles removed from my face". Include any specific concerns that you have. If you're uncertain about the exact procedure you need - particularly for facial skin lesions, where treatment options can include cryotherapy, shave excision, biopsy, or full excision - we strongly recommend booking a standard consultation with Dr Tomlinson rather than proceeding via the See and Treat pathway. If Dr Tomlinson feels that it would be more appropriate to examine your skin lesions and to discuss the options in person we will advise you of this and will not proceed with the See and Treat pathway.

What are you seeking to have done?

Funding type

I acknowledge that this outpatient service does not attract Private Health Insurance rebates

If DVA, Gold/White card number

Medical conditions

Medications

Allergies

I have no allergies I have allergies

Allergies

Imaging reports (if any relevant)

Photographs of lesion/lump/injury/area of concern

Our practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use your medical records: 1. In your medical treatment. This may include disclosure to individuals who are directly involved in your health care (and in any WorkCover or TAC claim) such as your General Practitioner, your other treating doctors and any third party that is appropriately involved with your case. If we refer you to another healthcare professional, such as an anaesthetist, hand therapist or radiology service we will disclose relevant information to them about your 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

As a patient of Dr Jill Tomlinson, I acknowledge that: - I have read the information above and understand why my 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 me; - I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in such circumstances; - If I have 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 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 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 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 personal information if it is incorrect. I will be provided with a written reason if a request for amendment is denied; - My 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 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

Place restrictions on the following potential uses of my clinical photographs (check all that apply):

do not place images in my medical record as part of my treatment do not send to another health practitioner who is treating me for this condition 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 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 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 me, except in circumstances where access might legitimately be withheld. I understand I will be given an explanation in such circumstances. - I understand that my photographs will not be used for any purpose other than set out above without my consent. - I consent to the use of my clinical photographs for the purposes set out above, subject to any limitations on the access or disclosure that I notify this practice of.

Thank you for completing this form. Once we receive it and the information has been reviewed by Dr Tomlinson we will email you a fee estimate for the requested treatment, with details of the relevant Medicare rebate applicable. If you wish to proceed you can then schedule a videoconsultation with Dr Tomlinson to discuss your medical history and concerns, the procedure, aftercare and recovery process, and risks. Your rooms procedure at 549 Bridge Road Richmond will follow that videoconsultation. A follow up appointment will generally be scheduled for around one week after the procedure; this may be in person or via videoconsultation depending on the aftercare that is required, such as removal of stitches.