NSBD - Consent Form

Which practice are you attending *

Title *

Please enter your title *

First name *

Last name *

Parent / Guardian: If a minor, full name of Parent or Guardian

Previous name e.g. Maiden name

Email address *

Phone *

Date of Birth *

Address *

Suburb *

Postcode *

State *

Do you have a medicare card? *

YesNo

Medicare Number *Please include your Reference Number: this is the number at the beginning of each individual person on your card

Concession Type

Card Number CRN or File No: *

CONSENT

In order to ensure you receive the best treatment, health professionals including general practitioners, specialists and allied health workers may need to share your personal information. Health professionals are legally and ethically obligated to protect the confidentiality of your personal information.In order to provide medical services to you, we may disclose your personal information to your referring health professional, and such other persons as they may nominate, and to medical specialists or hospitals. We may obtain your medical records from other organisations in order to assist you in your diagnosis and/or treatment. Your imaging report and other health information may also be disclosed by us for use in teaching medical students and medical research projects in a de-identified form. Sometimes we are required by law to disclose your personal information e.g. in response to a court subpoena. For additional information about how we collect, use and disclose personal information, please refer to the PRP Privacy Policy which is available at http://www.prpimaging.com.au/privacy or from PRP Diagnostic Imaging practices.

I consent to the terms outlined above *

Date Stamp