Patient Medical History Form

  • Patient Information

    • DD slash MM slash YYYY
    • *if patient is under 18 please complete parent/guardian details.

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  • Referring GP Specialist details

    • DD slash MM slash YYYY
    • *Medicare Rebate may not be redeemable without Referral

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  • Fee Payments & Cancellations

      • QANC adheres to a strict Cancellation Policy to minimise waiting times. Cancellations made on the same day as the appointment or non-attendance on the day will incur a cancellation fee of the full consultation cost.
      • This fee does not qualify for Medicare Rebate
      • Fee payment is required at the time of the consultation.
      • Payment methods include EFTPOS, credit card and cash.
      • A referral from a GP is valid for twelve months. A referral from a Specialist is valid for three months.
    • In accordance with the Privacy Act (1988), all information collected in this practice is treated as "sensitive information". To protect your privacy, this practice operates in accordance with the Act.

      We use the information you provide to manage your health care. You can assist in maintaining the accuracy of your information by advising the practice of changes of address, phone number etc.

      Selected information may be disclosed to various other health services involved in providing you health care management, (e.g GPs and other health professionals).

    • DD slash MM slash YYYY