New Patient Form
If you are new to Peregian Family Medical Centre, please fill out the below form before your appointment.
Fields marked with * are compulsory.
Consent to Collect, Use and Disclose Personal Information
Peregian Family Medical Centre (PFMC) endeavours to uphold the Australian Privacy Principals in collecting, maintaining and storing personal medical information in a private and secure manner. As a patient of PFMC, we ask that you provide us with your personal details and health information so that we may properly assess, diagnose, treat and be proactive in your health care needs.
We require your consent to collect, use and disclose your personal health information.
PFMC will collect your personal information for:
Communications regarding treatments, notifications about recommended preventative health care services and appointments, and for accounting and billing purposes
The diagnosis and treatment of health conditions, including disclosure to other doctors in the practice, specialists, locums and other health care providers to ensure quality patient care.
Accreditation and Quality Assurance activities within the practice, using de-identified aggregate patient health information.
To allow medical students and staff to participate in medical training and teaching, using deidentified aggregate patient health information.
Disclosure of Personal Health Information
PFMC will not disclose your personal health information to a third party unless:
You have consented to the disclosure
In accordance with the Privacy Act 1988, the disclosure is to your responsible carer, if you are physically or legally incapable of giving consent to the disclosure or for compassionate reasons, unless there is good evidence of your wish to the contrary.
Where legally obliged to disclose the information (e.g. notification of certain infectious diseases, suspected child abuse).
Disclosure is necessary to prevent a serious or imminent threat to an individual’s life, health or safety or to prevent a criminal offence or seriously improper conduct.
It is required for judicial, administrative or coronial proceedings or is requested under a court order or subpoena.
It is the subject of a search warrant, or is required to help identify or locate a patient.
Full or partial access to your medical records may be refused in circumstances where:
Disclosure of health information may result in physical or mental harm to you or any other person
The information may impact on the privacy of other individuals
Information relates to existing or anticipated legal proceedings
You have the right to decline to have your personal health information used in some of the ways outlined above, but this may limit our ability to manage your health care and to provide you with the best outcome. You have the right to amend information that you believe is incorrect.
Consent
I consent to PFMC handling my information for the purposes set out above, and I understand that I can request a copy of the PFMC Privacy Policy at any time.
