—Please choose an option—Mr.Ms.Mrs.Dr.

Date of Birth Gender —Please choose an option—MaleFemaleOthers

Medicare Number Refrence Number Medicare Expiry Date

Do you have Pension / Healthcare Card No. ? NoYes

Do you have DVA? NoYes

Do you identify as AboriginalTorres Strait IslanderOther

I acknowledge that I may be contacted by email, phone or text.

Dear Patient,
Your doctor will make independent professional decisions to optimize your clinical outcome. We value your privacy. All information about I consent to the disclosure of my personal health information by doctors practicing at Maple Street Surgery to other health care providers directly or indirectly involved in my personal health care or medical treatment. I consent to de-identified data (including, without limitation, photographs of my skin and any skin cancers) being used for medical training and medical research by Maple Street Surgery and such data being provided to third parties for these same purposes.

Your personal health information will not be sold by this practice to marketing companies and cannot be used for the purpose of promoting non-health related products or services.

FINANCIAL CONSENT:  I have been advised of the estimated costs in respect of the proposed medical services and or had the opportunity to observe same under patient information tab online. I accept responsibility for payment of an account for services rendered, including (if applicable) if a nominated insurer does not pay the anticipated rebate.

PERSONAL DECLARATION:  I have read and understood the information provided above.