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  • Confidential Patient Information

    Welcome to out practice. Our aim is to provide you with the best possible healthcare. Please complete all sections and read the Personal & Health information Consent section at the end of this form. Should you have any queries speak one of our team members, or Dr Sharp.

  • Personal Details

  • Date Format: DD slash MM slash YYYY

  • Claim Details

  • Concession Card

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  • Privacy

  • General Practitioner's details (only complete this section if your GP was not your referring doctor)

  • Referral Source

  • Medical Questionnaire

  • Medical History

    To ensure optimal medical and surgical care, it is very important that you answer the following questions thoroughly and honestly please.

  • Medications

  • Surgery


  • Personal and Health Information Consent

    We respect your rights to privacy and takes our privacy obligations seriously. We comply with the Australian Privacy Principles, found under the Privacy Act 1988(Cth). Our Privacy can be obtaned by requesting a copy at reception or on our website.

    We require your consent to collect personal information and health information about you. Please read this information carefully, and sign where indicated below.

    We collect information from you for the primary purpose of providing you with our healthcare services, We require you to provide us with your personal and health infoemation and your full medical history so that we may provide our services to you. We will also use the information you provide in the following ways:

    • Apprpriately manage our practice, such as conduction audits and undertaking accreditation processes, manage billing and trainning staff.
    • Effectively communicate with third parties,including Medicare Australia, private health insurers, govermment departments and other practitioners involved in your healthcare.

    During the post operative period, if you have any post operative complications, you may choose to send us questions or clinical photos foe your nurse and Dr Sharp to review. In signing this form and choosing to transmit images or questions to us via email or mobile phone post operatively, you acknowledge that these images may be transmitted to relevant clinicians via their devices (phones, ipad, email) for them to urgently review for post-surgical care as required.


  • For almost all patients, clinical photography will be taken to assist in your care. this ubcludes before amd after photos/videos in the clini, as well as intraoperative photos/videos during surgery. By signing this form, you provide permission for these images to become part of your confidential medical records.

    We also wold like to ask you for permission to ues these photos/videos for educational purposes in addition to their ues as part of your medical care. Names are not used and as far as possible, identifying factors are masked. these photos are extremely helpuful in teaching other doctors and helping other patients make an informed decision about their surgery, as you may have found yourself when resrarching your procedure. We are very grateful to those patients who permit us to share their images, and we are able to de-identify them if you wish-hoever you are under no obligation to agree to this.

    Do you consent to your before and after clinical photos being used:

  • Images will not be sold or trnsferred to any other entity for purposes that have not been agreed to.

    Declaration: I grant permission for photographs of me to be used in the formats indicated above. I am competent to execute this agreement.

  • Date Format: DD slash MM slash YYYY

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