Patient Form - QANC QLD ADHD & NEUROSCIENCES CLINIC

Patient Medical History Form

Patient Information
- Family Name*
- Given Name*
- Date of Birth*
  DD slash MM slash YYYY
- Preferred Name
- *if patient is under 18 please complete parent/guardian details.
- Parent / Guardian Details
- Family Name
- Given Name
- Relationship with Patient
- Address*
- Mobile*
- Home Phone
- Work Phone
- Email*
- Emergency Contact
- Phone
- Relationship
- Medicare Number*
- Reference Number*
- Expires*
- Next
Referring GP Specialist details
- Doctors Name
- Practice Name
- When Last Seen
- Referral Obtained
  DD slash MM slash YYYY
- *Medicare Rebate may not be redeemable without Referral
- Specialists Consulted (Incl. Psychiatric, Medical, Surgery, Others)
- Specialist Name
- Specialist Name
- Specialist Name
- When Last Seen
- When Last Seen
- When Last Seen
- Psychologist Consulted (Incl. Counsellors, Therapists, Diagnostic for testing etc.)
- Psychologist Name
- Psychologist Name
- Psychologist Name
- When Last Seen
- When Last Seen
- When Last Seen
- Previous Next
Fee Payments & Cancellations
- 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 Payments
  - 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).
- Privacy Policy*
  - I have read and accept the privacy policy.
- Consent & Information*
  - I give consent to QANC to access/disclose my personal health information by obtaining, accessing and/or communicating with my referring doctor and current/past medical providers or relevant services for the purposes of diagnosis, treatment and optimising my medical management as deemed appropriate and in accordance with Ethical and Best Practice Guidelines.
  - I agree to the terms of the above consent to access personal health data, cancellation policy, fees and payment policy
- Signature
- CAPTCHA - Please enter the code in the image
- Date
  DD slash MM slash YYYY

DOWNLOAD PDF VERSION HERE

Patient Medical History Form

Patient Information

Referring GP Specialist details

Fee Payments & Cancellations