Patient Registration / Upload Referral:


Please note that this form is for Kingswood Eye Centre patients in Glen Osmond only.

PRIVACY STATEMENT AND CONSENT FORM

In compliance with the privacy legislation information collected and disclosed about you requires your consent.

Such information including your diagnosis and treatment may need to be shared with Practice staff, specialists, optometrists and other healthcare providers involved in your care.

You can discuss any concerns you may have about how we handle your information with our staff.

consent to Kingswood Eye Centre collecting my personal information.  I understand that the purpose of the collection of this information is required to provide continuing medical services to me.    By providing your email address and mobile phone number you are consenting to Kingswood Eye Centre to transmit medical documents and information in relation to your care as required. It is your responsibility to ensure the nominated email address is secure and confidential. There is no guarantee that an email sent to us or by us will be secure, virus free or successfully delivered   I understand that the information collected may be used for the purposes of continuing care and may be disclosed to other health care providers or organisations involved in my care.

PAYMENTS

Please be aware that all accounts are to be paid in full unless prior arrangements have been made. Failure to pay accounts could result in legal action/debt collection which incurs an additional charge. If you are experiencing financial hardship please speak to the reception team prior to your consultation. Thankyou.

 

DISCLOSURE OF MEDICAL INFORMATION

Please list any Authorized people (Next of Kin/Partner/legal guardian etc) who you approve to make inquiries including appointment bookings, treatment plans, and medical updates on your behalf in the comment section in the above form.

 

IF THERE IS ANY POSSIBILITY THIS APPOINTMENT MAY BE WORKCOVER OR THIRD PARTY RELATED PLEASE NOTIFY THE RECEPTIONIST SO WE CAN ENSURE YOU ARE TREATED BY THE OPTIMAL HEALTH CARE PROVIDER FOR YOUR PRESENTING CONDITION.

Please contact us to speak to our friendly receptionist for further information or to book an appointment.

If you have any other questions, please contact us

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