PATIENT INFORMATION

PERSONAL INFORMATION

(if under 18yr)

Telephone

MEDICAL INFORMATION

(Number next to Name)

Emergency

GENERAL HEALTH

PLEASE NOTE: This practice does NOT BULK BILL. Payment is required on the day of consultation.

PRIVACY POLICY

PAYMENT IS REQUIRED ON THE DAY OF CONSULTATION.

GOVERNMENT REGULATIONS REQUIRE A CURRENT LETTER OR REFERRAL FROM A GENERAL PRACTITIONER OR OPTOMETRIST TO CLAIM YOUR REBATE BACK FROM MEDICARE.

The provision of quality health care requires doctor-patient relationship of trust and confidentiality.  Consistent with our commitment to quality care this practice hasdeveloped a policy to protect patient privacy in compliance with privacy legislation.

Cairns Eye Surgery would like you to be aware of the following:

In the collection of your personal information, there may be times where another health party will need to have information about you in order to provide a complete, holistic approach to your health care. There are some necessary purposes of collection for which information will be used beyond providing health care, such as professional accreditation, clinical auditing, finalization of accounts and so forth.

Should you have any queries, please feel free to take one of our brochures “Your Privacy – Our Policy” or speak directly to your doctor or one of the staff. If at any time you feel uncomfortable with regard to the collection of your personal information, please feel free to mention it.

In signing below, you agree to our Privacy Policy on the collection of your personal information and in the event of a debt you agree to pay any commission generated on the debt collected on your behalf by our nominated debt collection agency.

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