Patient information form

Patient Information

Parent's Medicare Card Details

For patients under 18. Required for the Medicare rebate.

Patient Health Fund

Next of Kin

Medical History

Acknowledgement of fee policy

Telephone consultations are paid one business day in advance. All other consultation fees are paid on the day by EFT, Visa or Mastercard. Surgical fees are due two weeks before your surgery; if they have not been paid, the procedure may be cancelled. I confirm the information I have provided is correct to the best of my knowledge.

Consent to collect patient information

Australian privacy law requires your written consent for a health professional to obtain your medical information or share it with another practitioner. I give my surgeon and Sunshine Coast Oral, Facial & Implant Specialists permission to: obtain my medical information, such as consultation notes and test results, from other medical or dental practitioners; communicate with other health professionals directly involved in my care; communicate with my referring practitioner; and take clinical, de-identified photographs and x-rays before, during and after my treatment, and use them for teaching, scientific papers or presentations. I confirm I have read and understood these terms.

Use of artificial intelligence (AI) in your care

Our practice uses AI tools to help with clinical documentation, including the Heidi platform, which prepares clinical notes from consultations and transcribes the letters our surgeons dictate. Your personal information is handled securely and in line with Australian privacy law. Continuing your care with our practice is taken as your consent to the use of these tools.

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Your form is sent securely to our practice team and used only for your care, in line with our privacy policy. Please call (07) 5406 0586 if anything here is urgent.