New Patient Medical Form

Next of Kin

Medical History Questions


The Privacy Act of 1988 requires all health practitioners to obtain consent from their patients to collect, use and disclose patients’ information.


Access Cardiology staff will collect information that is necessary for your treatment. Such necessary information may include:

♥ Full medical and psychological history.
♥ Family medical and psychological history.
♥ Ethnicity.
♥ Medicare / Private health fund details.
♥ Billing and accounting information.
♥ Contact Details.

The information will normally be collected directly from you; however, there may be occasions when it will be necessary to collect information from other sources with your prior consent. These sources may include but are not limited to:

♥ Parents about children.
♥ Children about their family.
♥ Schools and teachers.
♥ Other health care providers.

In emergency situations we may have to collect information from relatives or other sources without your prior consent.


With your consent we will use and disclose your information for purposes such as:

♥ Account keeping and billing.
♥ To reply to your referring doctor.
♥ Referral to another health care provider or hospital.
♥ Management of Access Cardiology including quality assurance, practice accreditations and complaint handling.
♥ To prevent or lessen a serious threat to an individual’s life, health or safety.
♥ Where legally required to do so e.g. by a court, mandatory reporting etc.
♥ To meet our obligations of notification to medical defence organisations or insurer.


You are entitled to have access to your own health records at any time convenient to all parties. Depending on the nature of the access requested a charge might be payable where the practice incurs costs in providing access. There are some circumstances in which access may be denied, but in such an event you will be advised of the reason. If you find any information we hold on you is inaccurate or incomplete, please advise us so that we can adjust your record. We are not able to erase the original record.

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If you’d like to fill out the form yourself please download, fill out & send to Access Cardiology.