Patient ID form

CLIENT DETAILS


GP (Medical)




MEDICARE CLAIMING DETAILS

(next to name)

Please provide claimant details for Medicare rebate:

(next to name)

MEDICAL HISTORY


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CONSENT TO COLLECT PATIENT’S INFORMATION

Recent changes to the Privacy Laws now mean that a person’s written consent is required for a health professional to obtain medical information concerning that person, and to communicate medical information about that person with another health practitioner.

In view of this, the following form will need to be signed if you are happy for Dr John Cosson to obtain such information and to liaise with other health practitioners concerning your condition.

give permission for Dr John Cosson

  1. To obtain medical information, details of previous consultation and results of investigations performed from other medical practitioners, hospitals and health care providers that pertain to my medical condition.

  2. To communicate with the referring medical practitioner concerning my medical condition.

  3. To communicate with other health professionals directly involved with my medical condition.

Please note: Any OPG’s (x-rays) or Scans which are left at the premises of Coastal Oral and Facial Surgery that have not been collected within 12mths will be disposed of.

(Parent/Guardian if Patient if under 18yrs)
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