Patient DetailsTitle* Mr Mrs Miss Ms Mstr Dr OtherGiven Name:*Surname:*DOB:* DD dash MM dash YYYY Address:*Suburb:*State:*State:NSWQLDVICACTTASSANTWAPost Code:*Mobile:*Home:*Email:* Postal Address Please select box if postal address is same as abovePostal Address:Suburb:State:State:NSWQLDVICACTTASSANTWAPost Code:Medicare / Health FundMedicare No.:*Exp:* DD dash MM dash YYYY Ref:*Health Fund:Membership No:Ref:DVA / Pension CardDVA Card (Colour):DVA Card (Number):Pension Card (Number):Next of KinNext of Kin (Name):*Next of Kin (Phone):*Relationship:*Referring DoctorName:*Phone:*Name of GPName of GP (if different from above):Phone:Address:Attach Referral (If Applicable)Attach a Referral Drop files here or Select filesMax. file size: 2 MB, Max. files: 3.Workers Compensation or Third Party ClaimsWorker’s Compensation / CTP / Lifetime Care & Support* Worker’s Compensation CTP Lifetime Care & Support Not ApplicableClaim Number:Date of Injury: DD dash MM dash YYYY Insurance Company:Case Manager:Case Manager Phone/Email:How did you find us?Website / Friend / Social Media / GP / Other*What's Your Social Media Handle?Add Dr Bish on Instagram @solimanplasticsurgerySocial Media HandleAccountsI agree to pay all accounts rendered by Dr Soliman unless otherwise pre-approved in writing by an insurance company.ReferralsI understand that even though a referral is not required for me to be reviewed, it is a legal requirement to enable me to claim a rebate with Medicare. A GP referral is valid for 12 months and a specialist referral is valid for 3 months. It is my responsibility to ensure that my referral is current prior to consultations.Collection Of Personal Information / PhotosDr Soliman collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we can properly assist, diagnose and treat illnesses and be pro-active in your health care. We may also use your information in the following ways.Administration purposes in running our medical practice.Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice.I have read the information above and understand the reasons why my information must be collected. 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 health care and treatment given to me.I am also aware of my right to access the information collected about me, except in circumstances where access might be legitimately withheld. I understand I will be given an explanation in these circumstances. I understand that if I request access to any information about me the practice will be entitled to charge fees to cover time and administrative costs which may not be covered by Medicare rebate.I consent to the handling of my information by Dr Soliman for the purposes set out above, subject to any limitations on access or disclosure that I notify this practice of.I understand that Dr Soliman may take photos or videos of me during consultations and/or surgery. These photos/videos will only be used for teaching or research purposes and will not reveal any of my personal details.Please tick:* I DO consent to photos/videos being taken of me I DO NOT consent to photos/videos being taken of meSignature and AcknowledgementI acknowledge that I have read and understood the information as outlined above.Patient Name:*Date:* DD dash MM dash YYYY Signature*Of Patient/Parent/Guardian/Power of Attorney (if applicable)CAPTCHAΔ
