Patient Consent Form

Welcome to Parfrey Place Medical Centre

To enable ongoing care and total quality improvement within this practice and in keeping with the Privacy Act 1988 and National Privacy Principles, we wish to provide you with sufficient information on how your personal health information may be used or disclosed and record your consent or restrictions to this consent.

Your personal health information will only be used for the purposes for which it is collected, or as otherwise permitted by law and we respect your right to determine how your personal health information is used or disclosed.

The information we collect may be collected by a number of different methods and examples may include medical test results, notes form consultations, Medicare and health insurance details, data collected from observations and conversations with you, and details obtained from other health care providers (eg specialist correspondence). By signing below you (as a patient/guardian) are consenting that on obtaining your personal health information it may be used or disclosed by the practice for the following purposes:

Follow up reminder/recall notices for treatment and preventative healthcare
For accounting procedure and the collection of professional fees
The diagnosis and treatment of any health condition, including the communication of relevant information only to practice staff, specialist and other healthcare providers to ensure quality care is provided
Accreditation and Quality Assurance activities are conducted by professionally trained non-treating GPs and other professionally trained and qualified persons eg Practice Managers
For legal related disclosure as required by a court of law
For the purposes of research only where de-identified information is used
To allow medical students and staff to participate in medical training/teaching using only de-identified information
For disease notification as required by law
For use when seeking treatment by other doctors in this practice

At all times we are required to ensure your details are treated with the utmost confidentiality. Your records are very important and we will take all steps necessary to ensure they remain confidential.

PATIENT CONSENT FORM

I,
give permission for my personal health information to be collected, used and disclosed as described above. I understand only my relevant personal health information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying the practice in writing.
Patient Name:
Date
MM slash DD slash YYYY
If patient not signing – Your Name (please print):
Your relationship to patient eg mother,father,guardian
Witnessed Staff
CAPTCHA