Patient Forms

North Coast Vascular request that you take this opportunity to review our Patient Forms.

If requesting an appointment please complete the form below and we will contact you as soon as possible. If you are a New Patient, we asked you to check in 5 minutes before your appointment time to allow for your personal data to be recorded. You can assist with this process by completing the New Patient Registration Form below.

Please also take the time to review our Privacy policy and our Patient Disclosure forms.

Request an Appoinment


                        If you are experiencing issues, or need help completing this form please contact us here


Title
Name
                            
                            
                                                    
                                                    First
                                                
                            
                            
                                                    
                                                    Last
                                                
                            
                        
Date of Birth
                            
                            MM slash DD slash YYYY
                        
                        
Phone Number
Mobile Phone
Email
                            
                        
First Appointment
OR Follow Up
Please choose your location
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New Patient Registration Form


                        If you are experiencing issues, or need help completing this form please contact us here




Your details
Title
Surname*
Given names*
Date of birth*
                            
                            DD slash MM slash YYYY
                        
                        
Gender*
Marital Status
Medicare number
Medicare line number
Expiry date
                            
                            DD slash MM slash YYYY
                        
                        
Pension, Health Care card, or DVA number (If applicable)
Expiry date
                            
                            DD slash MM slash YYYY
                        
                        
General Practitioner
Clinic Name
Occupation
Home address    
                    
                         
                                        
                                        Street Address
                                    
                                        
                                        Address Line 2
                                    
                                    
                                    City
                                 
                                        
                                        State
                                      
                                    
                                    Postcode
                                
                    
                
Postal address (if different from home address)    
                    
                         
                                        
                                        Street Address
                                    
                                        
                                        Address Line 2
                                    
                                    
                                    City
                                 
                                        
                                        State
                                      
                                    
                                    Postcode
                                
                    
                
Home phone
Work phone
Mobile phone
Email
                            
                        
Medication Summary
Do you have any allergies?
List or attach current medications
Attach a fileMax. file size: 20 MB.
Next of kin
Name
                            
                            
                                                    
                                                    First
                                                
                            
                            
                                                    
                                                    Last
                                                
                            
                        
Contact number
Who can we contact in an emergency?
Name
                            
                            
                                                    
                                                    First
                                                
                            
                            
                                                    
                                                    Last
                                                
                            
                        
Contact number
Relationship
Additional Information
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Patient Medication Summary Form


                        If you are experiencing issues, or need help completing this form please contact us here
Title*
Name*
                            
                            
                                                    
                                                    First
                                                
                            
                            
                                                    
                                                    Last
                                                
                            
                        
Date of Birth*
                            
                            DD slash MM slash YYYY
                        
                        
Phone Number
Mobile Phone
Email*
                            
                        
Do you have any Allergies? Please list them here.*
Please list your current list of Medications*
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Patient Privacy


                        If you are experiencing issues, or need help completing this form please contact us here





Patient Privacy is important to North Coast Vascular. We respect your rights and ensure all personal and health information remains private and confidential. Your health information refers to information pertaining to your health, medical history and past and future medical care.

We aim to protect the privacy and secure storage of your health information.  You can request a copy of our privacy policy, which includes information about the collection, use and disclosure of your health information.

We require your consent to collect personal information about you and to use the information you provide in the following ways:


 	Administrative purposes in running our medical practice.
 	Billing procedures, including compliance with Medicare and Health Insurance Commission requirements.
 	Disclosure to other involved in your healthcare including treating Doctors and Specialists outside this medical practice. This may occur through referral to other Doctors or for medical tests and in the reports or results returned to us following referrals.
 	Disclosure to other Doctors attached to the practice for the purpose of patient care and teaching.
 	For research and quality assurance activities to improve individual and community health care and practice management. Usually information that does not identify you is used but, should information that will identify you be required, you will be informed and given the opportunity to “opt out” of any involvement.
 	Where legally required to do so, such as producing records to court, mandatory reporting of child abuse.

Please read this consent form carefully and sign where indicated below.*
								
								I have read the information above and understand the reasons why my information must be collected
							

								
								I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the quality of health care and treatment given to me.
							

								
								I am aware of my rights to access the information collected about me, except in some circumstances where access may be legitimately withheld.  I will be given an explanation in these circumstances.
							

								
								I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.
							

								
								I consent to the handling of my information by the practice for the purpose set out above, subject to any limitations on access or disclosure of which I notify this practice.
							

								
								OR I am unsure and would like to discuss this further with someone from the medical practice before I sign.
							
Consent* I agree with the privacy policy.
Name*
                            
                            
                                                    
                                                    First
                                                
                            
                            
                                                    
                                                    Last
                                                
                            
                        
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Patient Disclosure


                        If you are experiencing issues, or need help completing this form please contact us here




I will provide North Coast Vascular with my personal details and a full medical history so that they may properly assist, diagnose and treat illnesses and be pro-active in my health care. 




I understand that at times my personal information may be required by this practice to be shared with other health professionals.This information may include, but is not limited to, a patient health summary, current medications list, past and active medical history, investigation reports and specialists letters, that may be required by this health service.




I understand and consent to my health information being shared with other health services and any auxiliary services that require my medical history. I am aware of my right to access the information collected about me.




I understand that if my information is to be used for any purpose other than set out above; further consent from me will be obtained. I consent to the handling of my information by this practice for the purposes set out above.
Consent* I agree to the disclosure statement.
Name
                            
                            
                                                    
                                                    First
                                                
                            
                            
                                                    
                                                    Last
                                                
                            
                        
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Patient Forms

Patient Forms

Request an Appoinment

New Patient Registration Form

Your details

Medication Summary

Next of kin

Who can we contact in an emergency?

Patient Medication Summary Form

Patient Privacy

Patient Disclosure

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1300 278 379 (1300 ART ERY)