PARENT ONE

Title:
MrMrsMsMissDrProfOther

First Name (required)
Middle Name
Surname (required)
Known as (if different from above)
Gender (required)
Date of Birth (required)
Address (required)
Suburb (required)
Phone Number (required)
Phone Number (secondary option)
Email (required)
Occupation

Do you have a Medicare Card? YesNo

If YES, please type your Medicare Number
Reference place on card
Medicare Expiry Date

Private Health Insurance YesNo

Private Health Insurance Fund Name (if applicable)

Hospital Cover YesNo

Membership Number
General Practitioner Name
General Practitioner Address
Suburb
General Practitioner Phone
 

PARENT TWO

Title:
MrMrsMsMissDrProfOther

First Name (required)
Middle Name
Surname (required)
Known as (if different from above)
Date of Birth (required)
Occupation
Phone Number (required)

Do you have a Medicare Card? YesNo

If YES, please type your Medicare Number
Reference place on card
Expiry Date
 

EMERGENCY CONTACT PERSON

Name
Relationship to you
Contact Number
 

CHILD (Please fill out this section if applicable)

First Name
Middle Name
Surname
Known as (if different from above)
Gender
Date of Birth
Do you have a Medicare Card?
YesNo

If YES, please type your Medicare Number
Reference place on card
Expiry Date
 

MEDICAL HISTORY

Parent One - Past medical & surgical history
Parent Two - Past medical & surgical history
Child - Past medical & surgical history
Parent One - Current medications including over the counter/herbs etc
Parent Two - Current medications including over the counter/herbs etc
Child - Current medications
Parent One - Allergies
Parent Two - Allergies
Child - Allergies
Please tick the box if the person is a smoker: Parent OneParent Two
 

PREGANCY DETAILS

Your obstetrician's name:

Mode of delivery:NormalForceptsVacuum extractionCaesarean

Length of pregnancy:Full termPremature

If your baby was premature, please state number of weeks:
Pregnancy issues or complications:
If you have a breast feeding lactation consultant please state their name:
Mode of feeding:Breast feedingBottle feedingMixed / both

If you are using formula, please state what type:

SOCIAL INFORMATION

Who else lives at home and how are they related? (eg, Grandparents, helpers):
Please list if there are any siblings and their ages:
Who looks after the baby?
Where does the baby sleep during the day and night?

IMPORTANT PRACTICE INFORMATION & FINANCIAL CONSENT

Flourish Care operates as a private billing practice. Bulk billing is not routinely offered.

All consultations will incur a fee, and an account will be issued at the time of service. Full payment is required on the day of attendance. Accepted methods of payment include cash, EFTPOS, and major credit cards. Fee information will be provided at the time of booking. Fees may be subject to change without prior notice.

For consultations where bulk billing applies, please review the statement below:

I acknowledge and understand that these services will be bulk billed, and that I have agreed to the assignment of my Medicare benefit to the treating General Practitioner. This acknowledgement is enduring and remains valid for ongoing care unless otherwise advised in writing.

After reading the above, please indicate your position: (required)
I agreeI disagree

CANCELLATION POLICY

A minimum of 24 hours’ notice is required for appointment cancellations or rescheduling. Failure to provide adequate notice may incur a cancellation fee, except in exceptional circumstances at the discretion of the practice.

PRIVACY

Amendments to the Privacy Act came into effect in December 2001. As a provider of healthcare services it is important that you are aware of how any personal information collected by this practice is used.
The personal information collected is that deemed necessary to best attend to, and treat the presenting health condition(s). Personal information is primarily used within the practice, but sometimes it is used to ensure quality and continuity of health care for you and must be partially or fully disclosed to others outside of the organisation, depending on the circumstances. e.g: when referring to a specialist medical practitioner or when requesting blood tests, urine tests, x-rays etc; when itemising accounts for Medicare.

FREEDOM OF INFORMATION

All patient files that include personal information, test results etc. are the property of this practice. However, should you choose to visit another Doctor at any time, copies of the appropriate files can be forwarded on receipt of your written request. Under no circumstance will this practice divulge personal information without your prior written consent.

We have read & understand all information provided above regarding fees, privacy & freedom of information.Parent OneParent Two

We are aware at the conclusion of all consultations there will be a request for full payment of the account. Parent OneParent Two

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