Patient Privacy and Consent

Please note: items marked * indicate mandatory fields.

Personal details
Residential Details

Residential Address

Postal Address (if different to Residential Address)

Contact details
Please enter phone number with area code included. No spaces please. eg. 0298765432
Please enter phone number with area code included. No spaces please. eg. 0298765432
Please enter your full mobile number. No spaces please. eg. 0412345678
10 Digits
1 digit next to cardholder's name
eg. HCF, NIB, Bupa
If patient is aged under 18 years, please provide parent details below:

Residential Address

"As Above" if applicable

 Postal Address (if different to Residential Address):

"As Above" if applicable
10 Digits
1 digit next to cardholder's name
Medical Information

Usual GP (if different from referring Doctor)

 Emergency Contact Person:

Authorising others to make enquiries on your behalf regarding your medical care:

 Along with nominating the third party (carer/family member) authorised to receive information, a further

indication could be provided as to what type of information can be released. In the event of a change in

personal circumstances (e.g. marriage separation) or some other change which may require a change

of nominated carer/family member authorised to receive patient information, it is the patient’s

responsibility to immediately inform the practice of such changes.

I authorise the nominated person to request and receive information on my behalf regarding my medical care,

results, appointments, prescriptions etc:

 To comply with the Commonwealth Privacy Legislation, Bulimba Dermatology requires your consent to collect

personal information. Please read this information carefully. Bulimba Dermatology collects your information in

order to identify your medical record and provide an accurate, quality health service. This means that we will

use the information you provide in the following ways:

•  To gain a history, diagnose disease and provide treatment where necessary.

•  Administrative purposes in running a specialist medical practice: including pre-operative and post-operative

calls using phone numbers and names you provide us, as well as hospital interaction for booking surgical

services, confirmation of appointments via SMS or emails, sending results of diagnostic investigations via


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

•  Disclosure to others involved in your medical care, including treating doctors, specialists, 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.


•  I have read the information above and understand the reasons why my information must be collected.

•  I am also aware that Bulimba Dermatology has a privacy policy on handling patient information.

•  I understand that I am not obliged to provide any information requested but failure to do so might

compromise the quality of health and treatment provided to me.

•  I am aware of my right to access the information collected about me, except in circumstances where access

might legitimately be withheld.

•  I understand 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 that set out above, my

further consent will be obtained.

•  I consent to the handling of my information by Bulimba Dermatology for the purpose set out above, subject

to any limitations on access or disclosure that I notify this practice of.

•  I understand that my personal information may go offshore, if I select email as a preferred mode of contact.

Please Note

Due to the privacy laws, results cannot be given to a third party unless written authorisation is obtained

or under special circumstances.


I, the patient/parent/guardian for this Patient Privacy and Consent Form, warrant the truthfulness of the information provided in this application.

Please type your First and Last Name
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