For PatientsReferral InformationYour AppointmentFormsPayment PolicyPatient InformationTreatment RoomTelehealthUseful LinksAlbany Day HospitalHollywood Private HospitalFAQs Patient Forms Patient Details Form Download the PDF Fill out the form online Patient Details Name*(As listed on Medicare Card) Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Name Middle Name Surname Preferred Name Date of Birth* DD slash MM slash YYYY Gender F M Other Residential Address* Street Address Suburb State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Residential Address same as Postal Address This is also my postal addressPostal AddressIf different to above Street Address Suburb State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneMobile*Consent I consent to receive appointment bookings, reminders, & general information via SMSEmail*By providing my email address, I consent to access my patient portal/information in the future MedicareMedicare Number*As shown on card Medicare Ref #*To the left of your name Medicare Card Expiry*Bottom right corner of card Concession CardConcession Card Type Concession Card Number Concession Card Expiry DVA ColourPlease select...WHITEGOLDDVA Number DVA Expiry Private HealthPrivate Health Fund Name Private Health Membership NumberDo you have hospital cover? Yes No Policy held for more than 12 months? Yes No Known excess?GPName of GP* Practice* Is this treatment related to a Worker's Compensation or Motor Vehicle Claim?* Yes No Emergency Contact / Next of KinEmergency Contact Name* Relationship to patient* Phone*Consent I authorise this person to take messages regarding reminders, change of appointments etc., on my behalfPayer / Account HolderIf patient is under 16Relationship Parent Guardian Name Date of Birth DD slash MM slash YYYY PhoneAddress Street Address Suburb State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Medicare NumberAs shown on card Medicare Ref #*To the left of your name Medicare Card Expiry*Bottom right corner of card Signature* PATIENT CONSENT TO COLLECTION, DISCLOSURE AND ACCESS OF PERSONAL INFORMATION The Privacy Act 1988 requires medical practitioners to obtain consent from each patient to collect, use and disclose their personal information and to acknowledge the patient’s rights to access the personal information held by the practitioner. Collection Great Southern Specialist Centre (GSSC) will collect information that is necessary to properly advise and treat you. Such necessary information may include your full medical history, family medical history, contact details, Medicare details, private health fund details, genetic information, billing and account details. The information will normally be collected directly from you but there may be occasions when we need to obtain information from other sources. Examples are: Other medical practitioners (e.g. GP’s, specialists, hospitals and day surgery units). Other health care providers (e.g. physiotherapists, occupational therapists, psychologists, pharmacies, dentists) Use and Disclosure With your consent, GSSC staff will use and disclose your information for purposes such as: Referrals to another medical practitioner, hospital or health care provider. Advice on treatment options. To meet our notification obligations to our medical defence organisations. Sending specimens for analysis. Quality assurance, practice accreditation and complaint handling. Account keeping and billing. To prevent a serious threat to an individual’s life, health and safety. Where legally required to do so such as producing records to court, mandatory reporting of child abuse or notification of diagnosis of certain communicable disease. Access You are entitled to access your own health records at any time convenient to both you and GSSC staff. In certain circumstances we may deny access where: To provide access would create a threat to health or life. There is legal impediment to access. The access would unreasonably impact on the privacy of another. In the interest of national security. We ask that where possible you make any request in writing. We may impose a charge for photocopying or for staff time involved in processing your request. Where you dispute the accuracy, we will take all steps to record all your corrections and place them with your file, but we will not erase the original records. I consent to Great Southern Specialist Centre collecting, using, and disclosing my personal information as outlined and I understand that: I am entitled to access my own health records except where access may be denied as outlined above. I may withdraw my consent except when legal obligations must be met. By signing this form, I also give permission for my personal information to be handed to a third party should I default on payment of my account. Consent* I have read and agree to the Patient Consent to Collection, Disclosure & Access of Personal Information.* Workers Compensation Details Form Download the PDF Fill out the form online Workers Compensation Patient DetailsPatient name* First Name Last Name Date of Birth* Day Month Year Patient Phone*Employer DetailsCompany Name* Representative Name* Insurance Company DetailsClaim ID* Company Name* Company Manager* Claim Manager* Claim Manager Phone*Claim Manager Email* Injury/Illness DetailsInjury/Illness*Location on Body*Location Where Injury Occurred*Date of Injury* Day Month Year Time of Injury* : Hours Minutes AM PM AM/PM Capsule Endoscopy Patient Form Download the PDF Fill out the form online Capsule Endoscopy Patient Information Patient ID (GSSC)* Date of Birth* Day Month Year Patient Name* First Name Last Name Address* Address Suburb State Postcode Phone*What medications are you currently taking? What medications have you taken in the last month? Have you ever undergone a capsule endoscopy?* No Yes Do you have any allergies?* No Yes If you do have any allergies, please provide details Have you taken NSAID regularly (one month or more)?* No Yes If you have taken NSAID, which one/s and for how long? Have you ever had episodes of total or partial digestive tract obstruction?* No Yes Have you ever had surgical interventions on your digestive tract?* No Yes If you have, what type of surgery? Have you suffered from diabetes mellitus?* No Yes Have you suffered from swallowing disorder or problems?* No Yes Have you suffered from any chronic GI diseases (e.g. Crohns Disease)* No Yes Do you have any implanted medical devices? (e.g. Pacemaker)* No Yes If yes, please provide details Have you taken - 2 x Pico-Salax sachets the night before your procedure, as instructed?* No Yes Have you taken - 2 x Pico-Salax sachets the night before your procedure, as instructed?* No Yes Time of Commencement* : Hours Minutes AM PM AM/PM Time of Completion* : Hours Minutes AM PM AM/PM Signature of Nurse*Signature of Doctor* GSSC Intravitreal Injection Consent Download the PDF