Registration Form Dr Rughani - Brisbane Plastic & Cosmetic Surgery

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Title*

First Name*

Surname*

Preferred Name*

Address*

Suburb*

Post Code*

Email Address*

Phone/(M)*

Do you consent to us leaving a message on these numbers identifying the practice?*

Date of birth*

Marital status*

Children*

Occupation*

Hobbies*

Next of Kin / Emergency Contact Person Name*

Next of Kin / Emergency Contact Person Phone Number*

Your Regular GP*

Your Regular GP Clinic*

Reason for Appointment*

Have you previously seen another specialist regarding this procedure?*

Have you been declined treatment by another plastic surgeon previously?*

Have you emailed us previously?*

Do you wish to receive monthly newsletters via email?*

Do you follow us on Instagram or Facebook?*

How did you hear about us?*

Notice of the Use of Heidi (Ai) During Your Consultation

Before we proceed with your appointment, we want to inform you about an important aspect of how we document our consultations. We utilize a note taking tool called Heidi to accurately and efficiently capture the details of our discussions and the outcomes of our appointments. Heidi ensures that we can focus more on our conversation and less on manual note taking, enhancing the quality of care you receive. Your consent is crucial for us to use this technology. Please understand that your information will be handled with the utmost care, and Heidi’s use is aimed solely at improving your healthcare experience

By signing this consent form, you are agreeing to allow your clinician to use Heidi during your consultation

Patient’s Full Name*

Date*

Signature*

USE OF PERSONAL INFORMATION CONSENT FORM

Amendments to the Privacy Act 1988 has brought the introduction of the Australian Privacy Principles (APPs), replacing the current National Privacy Principles (NPPs) from 14 March 2014. These amendments redefine how healthcare services can manage your information.

1. WHAT INFORMATION DO WE COLLECT ABOUT YOU?

At BPACS, Dr Rughani and staff collect information from patients primarily to provide the best quality and continuity of care. This may include other medical specialists, nurses, pathologists, healthcare providers and health administration services so that your health care is not compromised. We require you to provide us with your personal details and full medical history so that we may properly assess, diagnose, treat and be proactive in your health care. This includes your name, contact details, Medicare and health fund details. In addition to this, by signing this document you are agreeing for clinical photographs to be taken at our practice pre, post and intra-operatively. These photographs are used for clinical and diagnostic purposes only. Any photographs used outside of your medical file will require your specific consent. Information in relation to your visit is either kept safely and securely within the centre, or is secured with password protection in the cloud, with access limited to the BPACS team exclusively. Any personal information stored can be amended or deleted at your request.

2. WHY AND HOW DO WE COLLECT THIS DATA?

We are required to obtain your consent to collect personal information about you. The information we collect about you helps us to keep up-to-date details about your needs, so we can care for you in the best possible way. We also use the information to better manage and plan this service. We will collect this information directly through you and will use the information you provide in the following ways:

Administrative purposes in running our medical practice.
Billing Purposes.
Disclosure to others involved in your healthcare, including treating doctors and specialists outside the medical practice/day surgery. This may occur through referral to other doctors, or for medical tests and in reports or results returned to us through the referrals;
Disclosure for research and quality assurance activities to improve individual and community health care and practice management; and,
Emergency situations whereby medical officers/hospitals require access to patient notes for treatment purposes.

3. HOW CAN MY PERSONAL INFORMATION BE ACCESSED? If you have changes to your personal information or wish to review your personal information, please ask one of our friendly staff or speak directly with the Practice Manager.

Please Note:

This consent form is written in accordance with Brisbane Plastic and Cosmetic Surgery Confidentiality and Privacy Policy (September 2014). If you wish to read this document in full prior to signing, we can provide you with a hard copy at our Brisbane office an electronic copy can be emailed to you (at your request) for your reference. Please ask a receptionist for more information.

PATIENT PRIVACY CONSENT

I have read the information above and understand the reasons why my information must be collected. I am aware that BPACS has a privacy policy on handling patient information. I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me. I am aware of my right to access the information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I notify this practice of.

Patient Name*

Date of Birth*

Date*

Signature*

Patient Signature/Guardian/Responsible Person/Statutory Health Attorney
An authorised person/power of attorney to be contacted in emergency circumstances:

Name*

Phone No*

CAPTCHA

Dr Rughani

Notice of the Use of Heidi (Ai) During Your Consultation

USE OF PERSONAL INFORMATION CONSENT FORM

1. WHAT INFORMATION DO WE COLLECT ABOUT YOU?

2. WHY AND HOW DO WE COLLECT THIS DATA?

PATIENT PRIVACY CONSENT

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