Child and Parent/Guardian Registration Form

Child/Young Person's Details

Personal details

First Name *

Last Name *

Preferred name (optional)

Date of birth *

Gender *

MaleFemale Other

Additional information (optional)

Residential address (as per Medicare account) *

Postal address (if different from residential)

Is child Aboriginal or Torres Strait Islander? *

Account information

Medicare number *

Reference number *

Expiry *

Health Care Card

Expiry

Primary account holder *

Parent/guardian Other

Parent/guardian name *

Please specify name and details for invoicing *

Regular GP (if different from referring doctor)

Clinic

Parent/Guardian Details

Parent relationship status

Are parents separated/divorced? *

YesNoSingle parent

Are there any existing parenting, custody or guardianship arrangements for the child? *

Yes No

Please supply to our clinic by uploading here or sending directly to the clinic at your earliest convenience

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Parent/guardian 1

Relationship to child *

Title (optional)

First name *

Last name *

Preferred name

Date of birth *

Gender *

MaleFemale Other

Additional information (optional)

Phone *

Email *

Residential address (as per Medicare account) *

Postal address (if different from residential)

Medicare number *

Reference number *

Expiry *

Pensioner Concession Card / Health Care Card number

Expiry

Do you identify as Aboriginal or Torres Strait Islander? *

Do you require an interpreter? *

YesNo

Language required *

Parent/guardian 2

Please enter N/A if not applicable

Relationship to child *

Title (optional)

First name *

Last name *

Preferred name

Phone *

Email *

Additional parent/guardian information and contact details

Consent Form

*For parent/guardian 1

Your privacy and medical records

1. In accordance with section 6(1) of the Privacy Act 1988 (Cth) (Privacy Act),all information collected in this medical practice is treated as ‘sensitive information’. To protect your privacy, Hobsons Bay Paediatrics (the Practice) operates in accordance with the Privacy Act and its Privacy Policy. Your personal information is kept private and secure, as required by federal and state privacy laws. Please refer to our Privacy Policy for full details of how we handle your personal information, including how you may access and seek correction of your personal information, complain about a privacy breach, and how we will deal with that complaint. Our Privacy Policy is available from reception or on our website www.hobsonsbaypaediatrics.com.au

2. Hobsons Bay Paediatrics collects personal information pertaining to your child and your family for purposes related to (or in the case of sensitive information, directly related to) our functions or activities, including facilitating the delivery of health services to you from your health practitioner, informing you of services which may be relevant to you and to communicate with you on behalf of your health practitioner. We may not be able to facilitate the delivery of health services from your health practitioner to you if you do not provide this information. Your personal information may be disclosed to our related bodies corporate, health practitioner, and third-party services providers.

3. Your health practitioner uses the information you provide to manage your health care, which may include using the information for the following purposes (including instructing the Practice to use the information for the following purposes on your health practitioner’s behalf):

Collecting, recording and storing your personal and health information that will form part of an individual computerised medical record.
Issuing reminders for specific health checks that you may require, if any, as part of your consultation with your health practitioner.
Providing you with health information updates, general medical updates and providing your personal and health information to the relevant state and/or national recall reminder registers.
Using your personal and health information to undertake, however not limited to, administrative tasks involved in the running of the Practice, and for your health practitioner, billing tasks which includes compliance with Medicare, Health Insurance Commission and other relevant Government agency requirements.

4. Selected information may be disclosed to various other health care providers involved in supporting your health care management (e.g. pathology and imaging providers, hospitals or other specialists). You hereby acknowledge and consent to the disclosure and/or use of your personal health information by the Practice, your health practitioner and persons directly or indirectly involved in your personal health care or medical treatment for that purpose, including:

Sending specimens obtained from you to the necessary pathology provider for analysis. As a result, you understand that you may incur an out-of-pocket expense, by which a separate invoice will be issued by the relevant pathology provider. You understand that you will be liable for all expenses incurred.
Disclosing your personal and health information to the relevant medical and allied health service providers involved in your care.
Communicating with your teachers and/or other professionals involved in your care, where you have requested or separately consented that we may do so.
Disclosing de-identified personal and health information for research and quality assurance purposes undertaken by your health practitioner to improve the quality of both individual and community health care needs and medical practice management. The Practice will inform you when such activities are being conducted and give you the opportunity to ‘opt-out’ of any involvement at any time.
Using your personal and health information by your health practitioner and other authorised individuals involved in your medical care and treatment, both directly and indirectly.
Disclosing for legal related purposes as requested and required by a court or other regulatory body.
For medical training/teaching purposes where de-identified information is disclosed to medical students and staff.
For disease notification as required by the law.

5. You are not obliged to provide information requested of you, however your failure to do so may compromise the quality of care provided to you by your health practitioner.

6. You understand it is your responsibility to inform the Practice at the earliest opportunity of any changes to your personal and health information. If any information held about you is inaccurate, you may request to have this altered accordingly.

7. You understand your right to access both your personal and health information held by the Practice, except in circumstances where access is legitimately withheld. If your personal and health information is to be used for any other purpose, other than what is set out above, your further consent will be obtained.

If you have any questions regarding the management of your personal health information or need to arrange access to your records, please ask reception or your health practitioner, as appropriate.

Appointments and fees

1. You understand your health practitioner requires payment on the day for services they provide. Failure to make payment will incur an additional administration fee for the time and resources taken to recover full payment.

2. A non-attendance fee will be applicable for any missed appointments.

3. A late cancellation fee will be applicable for any appointments cancelled with less than forty-eight (48) hours of notice.

4. There may be additional charges incurred beyond the standard consultation fee if any additional tests and/or procedures are required.

Consent

Do you confirm that you have read this form, understood the appointment and fee information, and consent to the use of you and your child’s personal and health information by the Practice as stated above? *

Yes No

Do you consent to us communicating with you via SMS? *

Yes No

Do you consent to us communicating with you via email? *

YesNo

Do you consent to your health practitioner uploading or otherwise disclosing your personal and health information to certain AI technologies which assist your health practitioner with clinical dictation (converting voice recordings into medical documentation) in their delivery of medical care to you? *

YesNo

Please note:

Your health practitioner will only use AI technologies in a supportive capacity, and the technologies will not replace your health practitioner's professional judgement.
You can opt-out at any time.

Parent/guardian 1 signature *

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Parent/guardian 1 name *

Date *

If you have any questions or concerns about any of the information on this form, please contact Reception.

Shared Parenting Policy

*For parent/guardian 1

Hobsons Bay Paediatrics is committed to collaborating with you to provide the best care possible for your child. In signing this form, you accept the following regarding our shared parenting policy should this be of potential relevance now or in the future:

1. Parenting Orders

Parents/guardians are responsible for providing the practice with up to date Parenting Orders (Court Orders) if in place, notifyingthe practice if these Orders change.

2. Communicating details of an appointment time

The parent/guardian who arranges the consultation will, as appropriate, provide details of the appointment time to the other parent/guardian, including any changes to the date or time of the appointment. It is not the responsibility of thepractice to keep both parents/guardians informed about the appointment time.

3. Inclusion of information in reports

Information will be gathered from one or both parents/guardians who attend appointments and this may be included in reports.

4. Correspondence from doctor

Correspondence will be sent to theparent(s)/guardian(s) who attend the consultation.Parents/guardians may share letters of correspondence from their doctor with each other. However, it is not the responsibility of the practice to keep the other parent/guardian informed if they do not attend the consultation.

5. Requests for medical records

Requests for yourchild’s medical reports will be assessed by the practice in accordance with state and commonwealth privacy legislation. The practice requires a written request for records.

6. Payment of fees

The parent/guardian who attends the consultation is responsible for makingpaymentonthe day ofthe appointment. The practice does not get involved in financial arrangements between parents/guardians.

Parent/guardian 1 signature *

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Parent/guardian 1 name *

Date *

Referral and additional comments

Please ensure your child has an up-to-date referral. Referrals can be uploaded here or emailed to admin@hobsonsbaypaediatrics.com.au at your earliest convenience. Please note that appointments cannot be offered until a referral is received. *

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Additional comments