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Surgical Patient Information Form

We adhere to the National Privacy Policy Act 1998. The information you provide is confidential and will be handled in accordance with our Privacy Policy. Patient information collected by this clinic is used to assist in providing quality care and all information is treated confidentially. Some information may need to be communicated to other professionals in order to facilitate your care. Thank you for your assistance.

Medical Information

Next of Kin


Please complete your bank details for Medicare rebates if your consultation is determined to be medical:

By submitting this form, I, the patient, understand that the information supplied by me is correct to the best of my knowledge and the I have read the Privacy Policy Statement. The information collected by the clinic is to provide me with quality care and will be treated with confidentiality in the provision of that care. I understand that some operations or conditions require photographic records to be taken and recorded within my clinical file. By submitting this information, I consent to the collection of clinical data and by attending my consultation I consent to photographs being recorded for my clinical file. Photographs will be stored in accordance with the Privacy Policy and medical legislation. I consent to being contacted via phone, SMS or email by the practice.