Patient Registration Form

PATIENT DETAILS

First Name

Last Name

Preferred Name

Date of Birth

Gender

MaleFemale

English is a Second Language

YesNo

Ethnicity

ATSI

AboriginalTorres Strait IslanderNone of the Above

PATIENT CONTACT DETAILS

Home Phone

Mobile Phone

Work Phone

Email

Address

Postcode

City / Suburb

State

EMERGENCY CONTACT DETAILS

Name

Address

Postcode

City / Suburb

State

Home Phone

Mobile Phone

Email

Work Phone

NEXT OF KIN CONTACT DETAILS

Is the next of Kin same as your emergency (if yes, you do not need to fill this section)

YesNo

Next of Kin - Name

Next of kin - Email

Next of kin Home Phone

Next of kin - Mobile Phone

Best way to contact your next of Kin

Home PhMobile PhWork Ph

REGULAR GP

DR Name

PRACTICE NAME

PHONE NO

Address

MEDICARE

Do you use a different name in your medicare card?

YesNo

If you use Alias please write the Alias name & surname

Medicare First Name

Medicare Surname

Medicare Card No.

Expiry

CARD POSITION NUMBER *

Medicare Address (if different to your residential address)

PRIVATE HEALTH INSURANCE

Do you have private Medical insurance

YesNo

Provider

Membership No.

Expiry

PENSION / HCC/DVA Card

Do you have an aged pension card, healthcare card or a DVA card

YesNo

Card Type

HCCPension

Expiry(mm/yyyy)

DVA No.

Card No.

Consent to obtain and release information

I understand the nature and course of the treatments being offered to my by BailSafe Australia and member agencies. This has been explained to me by the relevant staff member and I have had the opportunity to ask questions. I consent to this treatment and acknowledge that I can cease treatment any time.

All information collected about your individual treatment is strictly confidential and kept securely and remains private ( Health Records Act (VIC) 2001).

Our practice will work closely with other agencies to coordinate the best support for you. This means your informed consent for the sharing of information will be sought and respected in all situations unless:

we are obliged by law to disclose your information regardless of consent or otherwise;
it is unreasonable or impracticable to gain consent or consent has been refused; and
the disclosure is reasonably necessary to prevent or lessen a serious threat to the life, health or safety of a person or group of people.
bail conditions are such that we are required to notify informants
subpoeanaed by a court of law

I hereby acknowledge that I am aware of my right to access my personal information *I hereby acknowledge that I am aware of my right to withdraw my consent at any time. *I understand that my provider must comply with relevant privacy laws and I will contact the organisation immediately if I feel that these laws have been breached. *I understand why certain information about me may need to be provided to other service providers in order to coordinate the best support for me *

You have the right to see this information through the freedom of information process by contacting the Freedom of Information Service.

I agree to the consent of release information terms above *

Telehealth Informed Consent

What is the purpose of this form?

The purpose of this form is to provide information to you about, and to obtain your consent to participate in, a telepractice consultation with your practitioner.

What is Telepractice?

Telepractice is the use of telecommunication to provide services to clients. The practitioner typically uses videoconferencing to administer client sessions in real-time but may utilise other formats, such as email, for related communication. Telepractice is sometimes referred to as telehealth, telerehabilitation, or telespeech.

What does a telepractice consultation involve?

A telepractice consultation usually involves some or all of the following:
Your practitioner will discuss your health and your health history with you and, where appropriate, will offer information and advice.
You may bring a support person with you, as you might in a face to face consultation.
If you attend a health service to participate in a telepractice consultation, other health professionals may be present and may need to examine you according to your practitioner's instructions.
A technical support person might be present for part of the consultation to assist with technical issues.
You are not permitted to video or audio record the consultation, unless your practitioner gives you permission to do so.

What are the potential benefits of telepractice?

Telepractice might:

Improve access to services
Reduce your need for travel
Decrease exposure to infectious disease

What are the potential risks of telepractice?

Telepractice might:

Be negatively impacted by technical problems, such as delays due to technology failures.
Not offer the same visual and sound quality for observations and modelling
Require someone onsite with you to support the practitioner
Not feel the same as an onsite session
Not achieve everything that is required and therefore require another telepractice consultation or a face to face consultation.
Include practices and procedures that are not as well understood in a telepractice setting as they are onsite
Increase exposure to privacy and digital security risks. (See next section.)

Will my privacy be protected?

This practice is subject to the Privacy Act 1988 and must comply with obligations related to the collection, use and disclosure of personal information, including through telepractice. The practitioner must maintain confidentiality and privacy standards during sessions, and in creating, keeping and transmitting records.

At times, audio and video recordings of sessions may be taken to support the practitioner ’s work, as might occur in a face to face consultation. You will be informed before a recording takes place and can refuse to be recorded for any reason. The practitioner will inform you of the reason for the recording and how it will be stored.

While the practitioner is obligated to meet standards to protect your privacy and security, telecommunication, including videoconference, may increase exposure to hacking and other online risks; as with all online activities, there is no guarantee of complete privacy and security protection. You may decrease the risk by using a secure internet connection, meeting with the practitioner from a private location, and only communicating using secure channels.

What does informed consent mean?

There are a few important principles related to informed consent:

You must be given relevant information. Ask the practitioner if you have questions about telepractice and the services offered.
You have the right to understand the information. Ask the practitioner if you do not understand.
You have the right to choose. If you do not agree to telepractice, you may refuse to participate. You may agree to or refuse specific activities and procedures.
You have the right to stop using telepractice at anytime. You can change your mind about telepractice or a specific activity or procedure, even in the middle of a session.
You can agree or refuse in writing or verbally. You may give your consent using the form below. You may also give consent or change your mind by telling the practitioner . Consent and refusal that you give verbally will be documented by the practitioner.
You can ask about alternatives to telepractice. If you refuse or change your mind about telepractice services, your practitioner will discuss any other options with you. The practitioner may or may not be able to offer alternative services.

I agree with the telehealth service terms above *

Please note : BailSafe Australia is a service which collaborates with other organisations to provide care to you. By completing this form, you agree to the reasonable consent to treatment , and sharing of information across BailSafe Australia agencies.

SIGNATURE

I AGREE THAT MY MENTAL HEALTH CARE PLAN WILL BE REFERRED TO BAILSAFE AUSTRALIA
LVL 40, 140 WILLIAM ST
MELBOURNE VIC 3000'
EMAIL: melbourne@bailsafeaustralia.com *

Patient/ Guardian Signature

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