Patient Registration and Communication Consent Form

Please bring a valid Medicare card to your first appointment*

Interpreter Required
2. Next of Kin/Emergency Contact (Only used in an Emergency)

3. Workers’ Compensation Information (Only complete if applicable)

4. Authorised Third Party Communication (People we can speak to about your care, can be the same as Next of Kin)

Please list any person(s) you authorise us to communicate with regarding your care. 

(Can be one or more people)

Authorised Persons *
You may update or withdraw this consent at any time by notifying our team in writing*

5. Privacy and Consent

The full version of our Privacy Policy is available on our website: www.wollongongsurgical.com.au

We collect your personal and health information to provide you with safe, high-quality medical care.

This may include sharing relevant parts of your information with:

– Hospitals and other medical professionals involved in your care

– Insurance companies and health insurance providers

– Government departments and agencies such as Medicare and the Department of Veterans’ Affairs

– Legal providers and representatives, including for workers’ compensation and other insurance-related matters

– Other third parties where required by law or where necessary for your ongoing treatment, billing, or claims processing

a. Electronic Records and Retention

Your information is stored in secure electronic medical records. We are legally required to retain records for at least 7 years after your last visit, or longer for minor.

b. Ai and Transcription Tools

Some of our doctors use secure AI-assisted tools such as Heidi, Dragon, and an off-site transcription typing service to help document your care. All information processed through these tools remains stored securely within Australia. If you do not want these tools to be used, please notify your doctor or a member of our staff.

c. Email/SMS Communication

While we take all reasonable steps to protect your privacy, these communication methods may not be completely secure.

d. Patient Responsibility

It is your responsibility to keep your contact information, Medicare, and health fund details up to date. Out-of-date information may cause delays, billing errors, or claim rejections, and could also result in your personal information being inadvertently sent to an incorrect recipient

e. Financial Consent

You are responsible for any fees not covered by Medicare, your health fund, or other third parties. Payment is due on the day of service, in accordance with our billing terms.

f. Recording Devices

For the privacy of all parties, no recording devices (including mobile phones or video) may be active during your consultation without the express prior permission of your doctor. Any request to record must first be discussed with our reception staff before your appointment.

6. Photography/Imaging Consent

I understand that photography and/or imaging (including intra-operative photos) may be taken for the purposes of:

– Clinical records and treatment planning
– Sharing with other medical professionals involved in my care for the purpose of treatment planning
– Teaching and training of medical professionals

I understand that these images will form part of my confidential medical record. Any use for research or teaching purposes will be de-identified unless specific written consent is provided.

I understand that I may withdraw my consent for future use of these images at any time by notifying Wollongong Surgical Associates in writing. I also understand that any images already taken and stored as part of my medical record will remain part of that record and cannot be removed, but will not be used for any further purposes without my consent.

Consent *
7. Emergency Treatment Consent

In the event of a medical emergency occurring on the premises, I authorise the doctors and staff of Wollongong Surgical Associates to arrange urgent medical care, including ambulance transfer, on my behalf. I understand that I am responsible for any associated costs not covered by Medicare or my health fund.

Consent *
8. Consent to Request and Release Information

I authorise Wollongong Surgical Associates to request, receive, and exchange relevant medical information (including reports, results, and clinical notes) from and with other health professionals, hospitals, or practices as necessary for my ongoing treatment and care. This consent remains valid unless revoked by me in writing.

Consent *
9. Communication Consent

Consent *
10. Acknowledgement

I acknowledge that I have read and understood the above and consent to the collection, use, and disclosure of my personal and health information as described. I have been provided with or directed to the Wollongong Surgical Associates Privacy Policy.

For Practice Use Only