Disclaimer Privacy Thank you for supplying this information as it will help us treat you as safely and efficiently as possible. It is necessary for us to collect and pass on information from patients and sometimes others associated with your care in order to attend to your health needs, and for associated administrative purposes. De-identified medical records (including photographs) are used by this practice for purposes of education, patient management, and research. Please advise the staff if you do not agree to this. You have access to any personal information of yours that we hold, and the right to know how that information is used. Please ask us if you would like a copy of our Privacy Policy or if you have any concerns regarding this process. ---------------------------------------------------- Notice: Please be advised that for your safety, CCTV surveillance is in use throughout our practice. Recordings are for security purposes only and handled in compliance with privacy laws. ---------------------------------------------------- Payments Payments for consultations are required on the day. Unless otherwise arranged, payments for surgery in hospital are to be made within 10 days. Claims to Medicare and/or health Funds are to be submitted after payment is receipted. Please indicate if you have assigned POWER OF ATTORNEY ?* —Please choose an option—YesNo Please indicate if you have an ADVANCED HEALTH DIRECTIVE ?* —Please choose an option—YesNo By completing this form I, the undersigned, declare that* Accept responsibility for the information provided above and agreement to the treatment plan.* I accept responsibility for payment of all accounts. Payments for consultations are required on the day. Unless otherwise arranged, payments for surgery in hospital are to be made within 10 days and claims to Medicare and/or health Funds are to be submitted after payment is receipted. * Understand that payments not made on time may be subject to collection charges* COVID19 Are you fully vaccinated for COVID ? —Please choose an option—YesNo Have you had COVID previously —Please choose an option—YesNo Approx Date of Onset, Still current?, Treating Doctor NOTE: If you do not receive confirmation after you click SUBMIT below, you will be asked to go back and enter any missing information and retry; if still unsuccessful after that, please contact us on 0738394717 or office@wtsc.com.au
