We require consent to collect personal information about you. Please read the following information carefully, and then check the box below.

I CONSENT TO THE FOLLOWING INFORMATION: - This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history, so that we may properly assess, diagnose, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways:- • Administrative purposes in running our medical practice • Billing purposes, including compliance with Medicare and Health Insurance Commission requirements. Unpaid accounts may be referred to a debt collector. • Disclosure to others involved in your health care, including treating doctors, or for medical tests and in the reports or results returned to us following the referrals. • Disclosure to other doctors in the practice, locums and by Registrars attached to the practice for the purpose of patient care and teaching • For preventative health purposes reminder letters can be sent can be sent to your postal address. Please let reception know if you prefer nor to receive these letters. • The practice may occasionally contact you by SMS if we are unable to reach you by other means for appointment reminders or other information. Please let reception know if you prefer not to be contacted by mobile phone. • Disclosure for research and quality assurance activities to improve individual and community healthcare and practice management. You will be informed when such activities are being conducted and given the opportunity to ‘opt out’ of any involvement. I have read the information above and understand the reasons why my information must be collected, I am also aware that this practice has a privacy policy on handling patient information. I understand that I am not obliged to provide any information requested of me, but my failure to do so might compromise the quality of the health care and treatment given to me. I am aware of my right to access the information collected about me, except in some circumstances where access might be legitimately withheld. I understand I will be given an explanation in these circumstances. I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained. I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I notify this practice of.