Paediatric Patient Information Form | Gold Coast Heart Centre

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Patient Information Form - Paediatrics

Prepare for Your Appointment

You can download a PDF copy of the Patient Information Form for your child's upcoming appointment, by clicking on the button below, print and complete the form and either email it to us at CWreception@gchc.com.au or bring a hard copy to your upcoming appointment.

Alternatively, you can complete the online Patient Information Form below and click the Submit button to send to our Reception Staff.

Paediatric Patient Information Form

Contact Us

Patient Details

PATIENT DETAILS

Patient Full Name:

Date of Birth:

Address:

GP Details

GP DETAILS

GP Name:

GP Address / Practice:

Free Text

MEDICARE & HEALTH FUND DETAILS

Medicare No:

Patient No:

Exp. Date:

Does the patient have a Pension Card?

Yes

If yes, Pension Card No:

Does the patient have a Health Fund?

Yes

If yes, Health Fund:

Membership No:

Parent Details

PARENT / GUARDIAN DETAILS

Parent/Guardian 1

Parent / Guardian 1

Are you the patient's Next of Kin?

Yes

Title:

Full Name:

Date of Birth:

Relationship to Patient:

Telephone (H):

Telephone (M):

Telephone (W):

Email:

Medicare No:

Patient No:

Exp. Date:

Parent/Guardian 2

Parent / Guardian 2

Are you the patient's Next of Kin?

Yes

Title:

Full Name:

Date of Birth:

Relationship to Patient:

Telephone (H):

Telephone (M):

Telephone (W):

Email:

Medicare No:

Patient No:

Exp. Date:

Next of Kin

NEXT OF KIN DETAILS (if different from above)

Name:

Relationship to Patient:

Telephone No:

Telephone Consent

TELEPHONE CONSENT:

For administration purposes we may be required to contact you by phone. Do you authorise our staff to:

Identify the name of our medical practice:

Yes

Leave a message on your answering machine/voice mail:

Yes

SMS Consent

SMS CONSENT:

Our practice uses an SMS reminder system to assist in the management of your child's appointments. Do you consent to the transmission of SMS (mobile text messages), for the purposes of:

Confirmation of Appointments:

Yes

Referral Reminders:

Yes

Appointment Reminders / Rescheduling:

Yes

Patient requests for general practice information:

Yes

Requests to call our practice:

Yes

Withdraw Consent

You may withdraw your SMS consent at any time by notifying our practice in writing.

Disclosure & Collection

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your child's personal details and a full medical history so that we may properly assess, diagnose, treat and be pro-active in their health care needs. This means we will use the information you provide in the following way – please see disclosure statement below:-

DISCLOSURE and COLLECTION STATEMENT:

I consent to the disclosure to and collection from medical/specialist practitioners, allied health practitioners and institutions that may require information about my child's medical history but only to the extent necessary to assess/treat the particular condition that my child has consulted the medical/specialist practitioner about. Disclosure and collection may also be required for administrative purposes in running our medical practice including Medicare, DVA and non-medical information for debt collection if applicable.

Consent for Disclosure & Collection of Information

Yes

Parent/Guardian 1 Signature:

Dated:

Parent/Guardian 2 Signature:

Date:

One Signature

NOTE: Only 1 signature is required

Email Consent

EMAIL CONSENT:

I consent to disclosing my child’s medical records to medical practitioners, hospital departments and other providers directly involved in my child’s health care management outside of this practice, by email.

I consent to corresponding with the Administration Staff at Gold Coast Heart Centre by email regarding any upcoming appointments, referral reminders and general administrative and accounting purposes.

I am aware that by sending my child's medical records via email and corresponding with administration at Gold Coast Heart Centre, that there may be a risk (as with any other document) that it could be read by someone other than the intended recipient.

I am aware that at any time I can withdraw my consent in writing.

Consent for Email

Yes

No (if no consent given, signature is not required)

Parent/Guardian Name:

Parent/Guardian Signature:

Date:

Third Party Consent

THIRD PARTY CONTACT CONSENT (Optional)

Name:

Relationship to Patient:

Telephone No:

Parent/Guardian Authority

Parent/Guardian Authority – Nominated Contact (third party)

I, the parent/guardian of the abovementioned child direct and authorise employees of Gold Coast Heart Centre to speak with the Third Party listed above, in the event that I am unable to be contacted, for the purpose of the management of my child’s appointments. I acknowledge that confidential information about my child’s medical condition will not be passed on to the nominated person without my express authority.

Nominated Contact Name:

Parent/Guardian Signature

Date

Thank you for contacting us.
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We pride ourselves on providing service excellence to our patients and referrers.

If you have any feedback on what we are doing well, or how we may improve, we appreciate you letting us know.

Email - reception@gchc.com.au

Website - complete our feedback form online

In rooms - confidential feedback form