Patient Forms
Our Mission

Our Mission is to provide a comprehensive range of professional health care services in a friendly, relaxed atmosphere.

Patient Forms

New Patient Information/ Change of Patient Information

  • Yes No
  • Next of Kin Details
  • Emergency Contact Details
  • Payer of Account for Child Under 16
  • Yes No
  • Aboriginal Torres Strait Islander Both Aboriginal and Torres Strait Islander No
  • Self Other
Your Privacy

In accordance with Australian Privacy Principles as defined by the Privacy Act 1998 all information collected in this practice is treated as “sensitive information’. There are three types of information in accordance to the Privacy Act – Personal Information, Health Information and Sensitive Information. Most common would be personal information. To protect your privacy, this practice operates in accordance with the act.
Please Note:
This consent form is written in accordance with Carina Medical and Specialist Centre’s Privacy Policy (March 2014). If you wish to read this document in full prior to signing, we can provide you with a hard copy. Alternatively, our policy can be found electronically through our website. Please ask a receptionist for more information. We use the information you provide to manage your health care. You can assist in maintaining the accuracy of your information by advising the practice of any changes to your address, phone numbers or Medicare details. We are not a bulk billing practice. Please speak to the receptionist BEFORE your appointment if you have any queries about our Doctor’s billing policies. Please be advised that you are free to withdraw, alter or restrict your consent at any time by notifying this practice in writing.