New Patient Form

Contact Details

Are you the account holder

Consent to the Collection and Use of Personal Information

This form explains how and why we collect and use personal Information and seeks your consent to certain collections and usos of that Information. The main purpose for collecting and using your Information is to provide you with the best possible health care. We must also comply with laws that require us to collect or disclose personal information about you. We wlll tell you about those legal requirements at the time that we collect the Information. Other uses and disclosure, of personal Information are set out below. Please tick If you agree to your

information being used In the following ways:

To assist in the development of service and delivery and planning facilities
To other medical practitioners, hospitals or health service providers to assist in any current/future treatments that realate to the condition you are currently being treated for
To your usual GP
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements
I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me.
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 am aware of my right to access the informaiton collected about me, except in some circumstances when access might be legitimately be withheld. I understand I will be given an explanation in these circumstances.

We may hold any of the following information about you

• Name

• Address (home and malling)

• Phone numbers (home, work, mobile)

• Email address

• Health Information

• Transactions details associated with services provided to you

• Any additional Information provided to us by you

• Any Information you provided to us through patient surveys

We use the personal information about you

• To assist In providing medical treatment and care to you, including ordering tests and communicating with other professionals Involved In your treatment

• To assist with any correspondence you have with us

• To assist with our internal administrative requirements

• To process private health fund claims or claims on government agencies

• To conduct quality reviews and clinical audits

• To provide information to Medical Practitioners, Allied Health Professionals and other health care facilities who provide necessary follow up treatments and ongoing care.

Mood Disorder Questionnaire

Has there ever been a time when you were not your usual self and... 

…you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble
If "Yes", how long did it last?
…you were so irritable that you shouted at people or started fights or arguments?
If "Yes", how long did it last?
…you felt much more self-confident than usual?
Self confident duration
…you got much less sleep than usual and found you didn’t really miss it?
If "Yes", how long did it last?
…you were much more talkative or spoke faster than usual?
If "Yes", how long did it last?
…thoughts raced through your head or you couldn’t slow your mind down?
If "Yes", how long did it last?
…you were so easily distracted by things that you had trouble concentrating or staying on track?
If "Yes", how long did it last?
…you had much more energy than usual?
If "Yes", how long did it last?
…you were much more active or did many more things than usual?
If "Yes", how long did it last?
…you were much more social/outgoing than usual, e.g., you telephoned friends in the middle of the night?
If "Yes", how long did it last?
…you were much more interested in sex than usual?
If "Yes", how long did it last?
…you did things that were unusual for you & other people might have thought were foolish, or risky?
If "Yes", how long did it last?
…spending money got you or your family in trouble?
If "Yes", how long did it last?

Thanks for submitting!