Patient Information Registration

ALL SECTIONS OF THIS FORM MUST BE COMPLETED, THANK YOU.

Emergency Contact

GP & Referrer

Medicare & Healthcare Fund

History of present illness


Current Medications


PERMISSION TO COLLECT AND STORE INFORMATION

We need to collect and store some information about you:
To help us provide good and safe treatment and to provide Government bodies with information to which they are legally entitled. These records will contain information including, but not limited to, your name, address, date of birth, Medicare number, referring doctor’s details and clinical imaging and records. Your medical information is also used, in an unidentifiable way, for auditing, research and education purposes.

We undertake only to collect information which is appropriate to your total care and to only use the information for its intended purpose. Your medical records are stored securely and can only be accessed by authorised staff. We are required to keep your records for up to seven years following your last consultation. If necessary, for the continuity of your medical care, this information may be shared with other health practitioners involved in your treatment. In certain circumstances there may be a legal obligation to disclose clinical information, for example to Government bodies. A full copy of our privacy policy is available on request.

Attach your referral form or any files you want to share here.
File types accepted are PDF, PNG, JPG. Upload file size limit is 4mb

“By clicking on the ‘SEND’ button below, I consent to my data being collected and stored as per Dr Crawford's Privacy Statement. Your data will be kept securely and protected.”