New Patient Information Online Form "*" indicates required fields Step 1 of 4 25% Contact and Personal InformationFirst Name* Middle Name Last Name* Known As Title* Dr Mrs Ms Miss Date of Birth* Address* Street Address Suburb City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone Work Phone Mobile* Email* Height (cm) Weight (kg) Medicare and Other Health Insurance DetailsMedicare No* Card Ref* Expiry* Health fund* Membership No* Do you have Hospital Cover? Yes No Have you been in the fund longer than 12 months?* Yes No Name of the person responsible for this account if different to the above GP DetailsGP Name* Practice Name* GP AddressEmergency Contact DetailsEmergency Contact Name* Relationship to Patient* Emergency Contact Phone* Patient InformationFEES: This is a PRIVATE BILLING Practice and the Fees are charged based on AMA recommendations. Initial and Subsequent Consultation costs are provided in an email that is sent when an appointment is made.All patients will be provided with a written Quote for any proposed surgery that they may require. Payment in FULL is REQUIRED ON the DAY of your Consultation. We can submit your A/C to Medicare on your behalf. The Item numbers and Costs may vary depending on your Examination at the time of the Consult Failure to attended an Appointment without having cancelled it with the Rooms at least 24 hours prior, may attract a fee which is not claimable through Medicare. PATHOLOGY: If you have a Colposcopy, Biopsy or any other Pathology carried out at your Consultation, you will receive a separate Pathology A/C via the mail. This will be partly claimable through Medicare. REFERRAL LETTER: We will require a CURRENT REFERRAL LETTER from your GP or Specialist prior to your Appointment. From your GP – this will last "12 months" From your GP – You can ask them for "Indefinite" Referral From a Specialist – this will only last "3 months" PRIVACY INFORMATION SHEETIntroduction: We are committed to protecting the privacy of patient information and to handling your personal Information in a responsible manner in accordance with the Privacy Act 1988 (Cth), the Privacy Amendment (Enhancing Privacy Protection) Act 2012, the Australian Privacy Principles and relevant State and Territory privacy legislation (referred to as privacy legislation). This Privacy Information Sheet explains how we collect, use and disclose your personal information, how you may access that information and how you may seek the correction of any information. It also explains how you may make a complaint about a breach of privacy legislation. This Privacy Policy is current as at 01/02/2020. From time to time we may make changes to our Policy, processes and systems in relation to how we handle your personal information. We will update this Privacy Policy to reflect any changes. Those changes will be available on our Website www.rajmohan.com.au and in the Practice. Collection: We collect information that is necessary and relevant to provide you with medical care and treatment, and manage our medical Practice. This information may include your name, address, date of birth, gender, health information, family history, credit card and direct debit details and contact details. This information may be stored on our computer medical records system.Wherever practicable we will only collect information from you personally. However, we may also need to collect information from other sources such as treating Specialists, Radiologists, Pathologists, Hospitals and other health care providers.We collect information in various ways, such as over the phone or in writing, in person by our Practice Staff or over the internet if you transact with us online. This information may be collected by medical and non-medical staff.In emergency situations we may also need to collect information from your relatives or friends.We may be required by Law to retain medical records for certain periods of time depending on your age at the time we provide services. Use and Disclosure: We will treat your personal information as strictly “Private and Confidential”. We will only use or disclose it for purposes directly related to your care and treatment, or in ways that you would reasonably expect that we may use it for your ongoing care and treatment. For example, the disclosure of blood test results and correspondence to your Specialist / GP or requests for x-rays. There are circumstances where we may be permitted or required by Law to disclose your personal information to third parties. For example, to Medicare, Police, Insurers, Solicitors, Government Regulatory bodies, Tribunals, Courts of Law, Hospitals, or Debt Collection Agents. We may also from time to time provide statistical data to third parties for Research purposes. We may disclose information about you to outside contractors to carry out activities on our behalf, such as an IT service provider, Solicitor or Debt Collection Agent. We impose security and confidentiality requirements on how they handle your personal information. Outside contractors are required not to use information about you for any purpose except for those activities we have asked them to perform. Data Quality and Security: We will take reasonable steps to ensure that your personal information is accurate, complete, up to date and relevant. For this purpose, our staff may ask you to confirm that your contact details are correct when you attend a consultation. We request that you let us know if any of the information we hold about you is incorrect or out of date.Personal information that we hold is protected by: Securing our premises; Placing passwords and varying access levels on databases to limit access and protect electronic information from unauthorised interference, access, modification and disclosure; and Providing locked cabinets and rooms for the storage of physical records. Corrections: If you believe that the information we have about you is not accurate, complete or up-to-date, we ask that you contact us in writing as per the above address. Access: You are entitled to request access to your Medical Records. We request that you put your request in writing and we will respond to it within a reasonable time. There may be a fee for the administrative costs of retrieving and providing you with copies of your Medical Records. We may deny access to your Medical Records in certain circumstances permitted by Law, for example, if disclosure may cause a serious threat to your health or safety. We will always tell you why access is denied and the options you have to respond to our decision. Complaints: If you have a complaint about the privacy of your personal information, we request that you contact us in writing. Upon receipt of a complaint we will consider the details and attempt to resolve it in accordance with our complaints handling procedures. For any queries or complaints please direct to: Kell Muir (Practice Manager) Dr Raj Mohan kell@rajmohan.com.au If you are dissatisfied with our handling of a complaint or the outcome you may make an application to the Australian Information Commissioner or the Privacy Commissioner in WA (Western Australia). Overseas Transfer of Data: We will not transfer your personal information to an overseas recipient unless we have your consent or we are required to do so by law. Pathology / Bloods / Radiology Results: All Results once to hand will be viewed by Dr Mohan. Dr Mohan or his Nurse will then call you with these results. OH&S Guidelines: Our Facility and Services endeavour to meet Occupational Health and Safety Guidelines for the health and safety of our patients attending our Practice. Our Bariatric chairs have a maximum weight limit of 272 kgs. Our Standard chairs have a maximum weight limit of 120 kgs. The Examination bed has a maximum weight limit of 200 kgs. Should you be outside of this weight allowance, please beware our Practice takes no responsibility for personal accident or injury. Contact: Please direct any requests in writing for access to Medical Records to: (Secretary) Dr Raj Mohan info@rajmohan.com.au **Medical History Form **1. Do you / your family or Carers have any symptoms consistent with COVID-1 (Fever, Coughing, Sneezing, Sore throat or difficulty breathing)?* Yes No 2. Have you returned from Overseas or Interstate travel within the last 14 days?* Yes No If so, have you self-isolated for 14 days?* Yes No 3. Have you been in close contact with a confirmed case of COVID-19?* Yes No If so, please NOTIFY US IMMEDIATELY as your Appointment unfortunately will need to be postponed until further notice and you are cleared by the Health Department.4. Are you Vaccinated?* Yes No How many times have you been Vaccinated ?* Vaccination Certificate required prior to Entry to Practice – please upload or Bring Paper CopyMax. file size: 100 MB.MEDICAL HISTORYList of Medications:Do you suffer from any Allergies?* Yes No List if Yes:Have you had any Previous Surgery?* Yes No List if Yes:Are you under the care of any other Specialist/s?* Yes No List if Yes:Do you have any other Medical Conditions?* Yes No List if Yes: If Operation photos are taken - would you like an emailed copy?* Yes No Consent to Medical Authority Release Form*This is to certify that I allow Dr Raj Mohan's office to release my Medical History on my behalf to a Medical Doctor, 3rd party, Insurance Company, Research Trials and anyone relevant to the management of my health. Yes, I agree to release my medical history to a third party No Patient's Name* Date* Signature*
