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Completion of the Practice Consent and Confidentiality (PCaC) form is required prior to having a consultation or procedure with specialists from Colorectal Surgeons Sydney.


Please note: questions indicated by * are mandatory fields

YOUR DETAILS


Title *

Given Name *

Last Name *

Date of Birth (mm/dd/yyy) *

Address (Home)*

CONTACT DETAILS


Preferred contact phone number *

Work phone number

Home phone number

Mobile phone number

Email Address *

MEDICARE DETAILS


Medicare Number

Medicare Reference Number

HEALTH FUND DETAILS


Private Health Fund

Health Fund membership Number

NEXT OF KIN DETAILS


Next of Kin Name *

Next of Kin Contact Number *

Next of Kin's Relationship to you: *

REFERRING DOCTOR DETAILS


Referring GP or doctor

Usual GP (if different from above)

Usual GP contact number

CONSENT TO COLLECTING AND SHARING INFORMATION ABOUT YOU

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in the following ways:
1. Administrative purposes in running our medical practice.
2. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
3. Disclosure to others involved in your health care, including referring and treating doctors and specialists outside this medical practice as advised by you.

I understand the reasons why my information must be collected.
I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me.
I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.
I understand that if my information is to be used for any purpose other than the above, my consent will be sought.

I confirm that I have read and understand the above CONSENT TO COLLECTING AND SHARING INFORMATION ABOUT YOU policy and agree to these terms

CANCELLATON POLICY


Waiting lists for consultations and surgical procedures are often booked far in advance. Therefore, to avoid under-utilisation of the waitlist, a cancellation fee of $150 will be charged for any cancellation of consultations within 24 hours and cancellation of a hospital procedure will incur a cancellation fee $250 if cancelled within 48 hours of planned procedure. Cancellation fee payment is required before any further booking can be accepted.

I confirm that I have read and understand the above CANCELLATION POLICY and agree to these terms

CLINICAL EXAMINATION AND OFFER OF SUPPORT PERSON POLICY


Colorectal conditions may require beside examination, sometimes a gloved Digital Rectal Examination(DRE) or proctoscopy. This will be discussed with you by your colorectal surgeon, and if you are agreeable verbal consent obtained. If you would like to have a family member or friend or one of our staff present as a support person in the room when your specialist examines you, then please mention this to the receptionist or specialist. If you feel uncomfortable about having an examination, please mention this to your receptionist or specialist surgeon. On occasions the specialist will insist one of our support persons being present during a clinical exam for their own protection.

I confirm that I have read and understand the above CLINICAL EXAMINATION AND OFFER OF SUPPORT PERSON POLICY and agree to these terms.

Additional Comments:


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