Sydney Vein Clinic Disclosure Agreement

Due to the Federal Privacy Act 1988, we require your written consent to collect personal information about you.  Please read this information carefully and sign where indicated below.

We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose and treat you.  We may need to collect information from previous doctors, health care workers, pathology or x-ray services that you have consulted with, for the primary purpose of providing quality health care.  This means that we will use the information you provide in the following ways:

Best assess your health care needs and provide medical treatment.

Administration purposes in running our practice.  We may need to contact you using phone numbers provided by you.

Billing purposes and debt collection, including compliance with Medicare and Health Insurance Commission requirements.

Disclosure to others involved in your care, including treating doctors, specialists and hospital booking staff outside this practice.  This may occur through referral to other doctors, surgery at hospitals, for medical tests and in the reports or results returned to us following the referrals.

Collection of data for research purposes.  This information is used to improve our treatment protocols (please refer to Sydney Vein Clinic’s Privacy Policy on our website)

You may be contact ed for follow up in the future to ensure the long term results of your procedure.

You have the right to access and correct any personal information [Practice Name holds about you.

 

First Name: …………………………………………  Last Name:  …………………………………………

 

Date of Birth: …………………………………………

 

Address: .………………………………………………………………………………………………………....

 

Suburb: ……………………………………  State: …..……… Country: ……………………………………..

I have read the above information and voluntarily give my consent


 

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Signature: ……………………………………………… Date (D/M/Y):   …..... / ……… / ……...