Subiaco Foot Clinic New Patient and Medical History Form

Recent requirements under the Health Privacy Act state that we now require your consent to collect information about you. 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. &#13;&#10;&#13;&#10;This means we will use the information you provide in the following ways: &#13;&#10;• Administration purposes in running our practice &#13;&#10;• Billing purposes, including compliance with Health Insurance Commission requirements &#13;&#10;• Relating your information to others involved in your care, including your general practitioner and specialists outside this practice. This may occur through referral to other doctors or for medical tests. &#13;&#10;• Occasional marketing emails notifying existing patients of special offers or changes at the practice.&#13;&#10;&#13;&#10;Please let us know if you do not want your records accessed for these purposes and we will note this in your record accordingly. If you consent to the handling of your information for the purposes set out above, please sign and date below. &#13;&#10;

Street Address
Street Address Line 2
City	State
Postal Code

NEW PATIENT & MEDICAL HISTORY FORM

Personal & Contact Information

Medical History

Foot / Leg History