Patient Registration Form

PATIENT DETAILS

First Name

Last Name

Date of Birth

Gender

MaleFemalePrefer not to say

Home address

Street address

City

State

Postcode

Child's Medicare number

Parent or Guardian's details

Parent or Guardian's name

Email address

Mobile Phone

Parent or Guardian Medicare details

Parent or Guardian's Date of Birth

Privacy and consent

Both parents generally have the right to access health information about their child, unless a court order is in place stating otherwise. Is there a court order restricting the right of a parent to access this patient's health information? *

YesNo

Do you give permission for the patient's doctor to correspond with the patient's school, General practitioner or allied health professional for clinical purposes? *

YesNo

Your doctor may use an AI scribe (Heidi AI) to help maintain accurate records of your appointment. Do you consent to the use of this software? *

Yes No

PRIVACY POLICY Paediatric Outreach Services Queensland (POSQ) collect personal information to assist with the provision of health care and directly related services. Instances in which POSQ may collect, use or disclose personal information include, but are not limited to: • Use by a multidisciplinary treating team; • Assessment for provision of health care services;• Correspondence with health care professionals, Medicare or your private health fund;• Emergency situations where a patient’s life is at risk and consent cannot be received;• Hospital management processes relating to risk management, safety and security activities, quality assurance and accreditation activities; • Education of health care workers or the placement of students and trainees; • Medical records maintenance as required under our policies and by law; or • Other purposes required or permitted by law.

I agreeI do not agree

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

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