HealthLink EDI: myhcardi
Fax: 03 9854 6445
Fax
03 9854 6444
Phone
Locations
Locations
Email
referral@myheartcardiology.com.au
Please wait while we submit your data.

Patient Registration Form

FOR PATIENTS
Please fill the form below before your appointment
Patient Information:
Title:
First Name: *
Last Name: *
Preferred Name:
Gender:
Date of Birth: *
Home Phone:
Mobile: *
Occupation:
Email:
⠀ *
Address *
Are you of Aboriginal or Torres Strait Islander origin?
Medicare and Insurance details:
Medicare number: *
Reference number: *
Expiry:
Pension / Health Care Card number:
Veteran Affairs number:
Expiry:
⠀
⠀
Private Health Fund:
Membership Number:
Reference Number:
Date Commenced:
Next of Kin / Emergency Contact:
Name:
Home Phone:
Mobile:
Relationship:
Address:
Referring Doctor Details:
Referring Doctor Name:
Phone:
Fax:
Clinic Name:
Clinic Address:
Is your referring doctor also your usual GP?
Usual Doctor & GP Details:
GP Doctor Name:
Phone:
Fax:
Clinic Name:
Clinic Address:
⠀ *
⠀ *
Our Policies for Medical Records Storage, Management & Artificial Intelligence Use
  • Your medical records will be securely stored and managed using our clinic's patient management software. This system ensures the confidentiality of your personal health information and complies with all applicable privacy laws and regulations.
  • Access to your records will be restricted to authorised personnel solely for purposes of providing medical care, billing, and related administrative tasks.
  • This consent form also seeks your permission to use artificial intelligence (AI) to capture and transcribe conversations between you and your clinician.
  • The transcribed notes will be reviewed and verified by your clinician before being added to your medical records. Protecting your personal and health information is our utmost priority.
  • All notes, letters, and transcriptions are securely stored and are only accessible to authorised personnel in your clinic, for a short period of time nominated by your clinician.
  • Your information will be treated with the utmost confidentiality in accordance with the Australian Privacy Principles and the Privacy Act 1988. Your personal and medical information will not be shared with any unauthorised third parties.
  • You have the right to withdraw your consent at any time without affecting your ongoing care.
  • Your information is used solely to support your care and is not used to by third parties, nor used for marketing purposes.
  • By signing below, you acknowledge that you have read and understood the information provided above, as well as that provided verbally by your clinician. You consent to the use of information technology and AI software during your consultations for the purpose of medical documentation.
⠀ *
Please sign the form using the signature area below:
Patient Signature *
Clear
Full Name: *
0.00