PARADISE ARTHRITIS & RHEUMATOLOGY

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PARADISE ARTHRITIS & RHEUMATOLOGY Rheumatologists Paradise Arthritis & Rheumatology Dr Jennifer NG Level 4, Suite 5 Dr Jacklyn Chay 123 Nerang St, Southport 4215 Dr Sateesh Shankaranarayana Ph: 0755 915 542 Dr Jeff Tsai Fax: 0755 919 128 Email: reception@panr.com.au Nurse Practitioners Ann Robinson Tammy Schmidt APPOINTMENT FOR: DATE and TIME: PLEASE NOTE OUR POLICY REGARDING APPOINTMENT CONFIRMATION/CANCELLATION There is a list of people waiting for URGENT new consultations so appointment time each day is a precious commodity. Please complete information and bring with you to your appointment. To avoid cancellation of your appointment you are responsible for confirming your appointment date and time a minimum of 24 hours in advance of your consultation. If you do not confirm your appointment 24 hours in advance and we are unable to contact you, your appointment may be automatically cancelled and another patient on the waiting list will be allocated your appointment and you will need to be rescheduled at Dr s discretion. Thank you for making an appointment. We are pleased to have you as a new patient and enclosed is some information to assist you with your visit to our practice. Practice Hours: Monday Friday 8.30am 5pm On the day of your appointment please bring your referral and any other information that may assist in your care.

Please NOTE we do not do worker s compensation claims. Consultation Fees: All consultation fees are Medicare rebatable. We can do the Medicare rebate if your details are registered with Medicare. We do not accept cheques or gap payments. If an injection is required for pain relief (at the Dr s discretion) the injections are at an extra charge. Fees are discounted for Aged Pensioners and Health Care card holders. Please note that our consultation is payable in full on the day of your appointment. At the time of making the appointment the fee structure will be explained to you. General information for your visit: Free underground parking is available at Pacific Private Clinic entry is via Cougal Street. Arrival: Please arrive at least 10 minutes before your appointment with your referral, pathology, Medicare, Health Care/Aged Pension cards for registration. In many instances your GP/Specialist may fax or email your referral and pathology prior to your visit. (GP referrals are valid for 12 months, specialist referrals are valid for 3 months). Cancellations: There is an appointment wait list to see the Doctor s here at Paradise Arthritis & Rheumatology and there are many patients who would be very appreciative if they were contacted to have their appointment moved to an earlier time. Please give 48 hours notice of any cancellation. General: Thank you once again for making an appointment with us. We look forward to meeting you and we hope this information assists you. Should you have any questions, please do not hesitate to call 0755 915 542. Yours sincerely Maureen Hedges Practice Manager

Your personal details Your name DOB Address Telephone Sms Y or N (please circle) Email Do you allow us to send requested information via the email listed above Y or N Gender Female/Male Current occupation Previous occupation if retired Medicare number ref Exp Private Health Fund Fund No Dva Pension No Exp Your General Practitioner Your next of Kin Name Telephone No Relationship Permission to contact Y or N (circle) (If unable to contact you or emergency) Medications list (or attach list) 1. 6. 2. 7. 3. 8. 4. 9. 5. 10. Allergies to any medications

Major illness or hospitalisations Year Hospital/city 1. 2. 3. 4. 5. 6. Please tick the following if you ever had; if you answer yes please write AGE or YEAR started Yes No Yes No High blood pressure Thyroid problems High cholesterol Miscarriages (female) Heart attack Back/spine problems Stroke/TIA Rheumatoid Arthritis Emphysema/bronchitis Osteoarthritis Asthma Fibromyalgia Stomach ulcer osteoporosis Bowel problems Broken bones after age 50 Kidney problems Depression Diabetes Severe allergies Blood clots Psoriasis Dry eyes/mouth Other autoimmune diseases Iritis/uveitis Gout Other Other Father Mother Brother(s) Sister(s) Son(s) Daughter(s) Your family medical history If Living Age Any major medical conditions Age of death If Deceased Cause(s) of death Rheumatoid arthritis Lupus/SLE Crohn s/ulcerative colitis Please tick yes if there is blood family history, if yes, give relationship Relationship Relationship Osteoporosis Ankylosing Spondylitis Psoriasis

Your social history Have you ever smoked? Y or N (circle) if yes approximate number per day? How many years have you smoked? If stopped, when How much alcohol do you drink a day? (N/A if you don t drink) Relationship status If married, health of spouse (circle) Good Poor If poor, give details Health of others at home (circle) Good Poor If poor, give details I have read and understood the privacy policy The details given above are true and correct as of this Date Signature

WE RESPECT YOUR PRIVACY We are committed to protecting the privacy of patient information and to handling your personal information in a responsible manner in accordance with the Private Act 199 (Cth), the Privacy Amendment (Enhancing Privacy Protection) Act 2012, the Australian Privacy Principles and relevant State and Territory privacy legislation (referred to as privacy legislation). This Privacy Policy explains how we collect, use and disclose your personal information, how you may access that information and how you may seek the correction of any information. It also explains how you may make a complaint about a breach of privacy legislation. This Privacy Policy is current from 07/07/2015. From time to time we may make changes to our policy, processes and systems in relation to how we handle your personal information. We will update this Privacy Policy to reflect any changes. Those changes will be available on our website and in the practice. We collect information that is necessary and relevant to provide you with medical care and treatment, and manage our medical practice. This information may include your name, address, date of birth, gender, health information, family history, credit card and direct debit details and contact details. This information may be stored on our computer medical records system and/or in hand written medical records. Wherever practicable we will only collect information from you personally. However, we may also need to collect information from other sources such as treating specialists, radiologists, pathologists, hospitals and other health care providers. We collect information in various ways, such as over the phone or in writing, in person in your Paradise Arthritis and Rheumatology practice or over the internet if you transact with us online. This information may be collected by medical and non-medical staff. In emergency situations we may also need to collect information from your relatives or friends. We may be required by law to retain medical records for certain periods of time depending on your age at the time we provide services. We will treat your personal information as strictly private and confidential. We will only use or disclose it for purposes directly related to you care and treatment, or in ways that you would reasonably expect that we may use it for your ongoing care and treatment. For example, the disclosure of blood test results to your specialist or requests for x-rays. There are circumstances where we may be permitted or required by law to disclose your personal information to third parties. For example, to Medicare, Police, insurers, solicitors, government regulatory bodies, tribunals, courts of law, hospitals, or debt collection agents. We may also form time to time provide statistical data to third parties for research purposes. If you have any questions regarding the information we collect from you and hold in your medical records, please do not hesitate to ask us. We are acting in your interests at all times.

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