Online New Patient Form for: Dr Subash Balakrishnan

Please complete the new patient form below to ensure we have all your correct and up to date details for any appointments or procedures.

Personal Details

Title *

First Name *

Last Name *

Preferred name

Date of Birth *

Gender *

MaleFemaleUnspecified

Pronouns *

she/herhim/hethem/they

Best contact number (mobile preferred) *

Email address *

Home address (including post code) *

Medicare Card Number *

IRN (number next to your name) *

Medicare expiry date *

Are you (the patient) under the age of 18? *

YesNo

If under the age of 18, further questions will appear to complete for the parent/guardian for Medicare claiming

Please provide the Medicare number and IRN for the parent/guardian *

Please provide full legal name of parent/guardian *

Please provide date of birth of parent/guardian *

Do you require an intepreter for your consultations? *

YesNo

If yes, which language? Or do you have a family member who can attend and interpret for you? *

Do you have Private Health Hospital cover? *

YesNo

If yes, which company is your insurance through? *

What is your member number? *

Are you a DVA member? *

YesNo

If yes, what is your DVA number? *

What type of DVA card? *

WhiteGold

Are you a Workcover or Third Party Claim patient? *

YesNo

Workcover Case/Claim Number *Please note: if Third Party or Workcover do not agree to pay for the consultation, you will be sent an invoice to pay. Please ensure they are aware of your appointment and have approved any consultations.

Please provide your case manager contact details (phone and/or email): *

Emergency contact name: *

Emergency contact phone number: *

Emergency contacts relationship to you: *

Referring Doctor *

Usual GP *Please enter in the Doctors full name and the practice they work at

Medical History

Do you have any cardiac (heart) conditions? *

YesNo

If you do have cardiac conditions please provide details below: *

Do you have any respiratory (lung) conditions? *

YesNo

If you have respiratory conditions, please provide details below:

Do you have any renal (kidney) conditions? *

YesNo

If you have renal conditions, please provide details below:

Have you recently had any imaging or scans done? *

YesNo

If yes, which radiology practice were they done and when? *

Are you diabetic? *

YesNo

Please list your diabetic medication/management below: *Please also include the name of the specialist/Dr that manages your diabetes medication

Are you taking blood thinners or anticoagulation medication? *

YesNo

Please list details of the medication below: *Please also include the name of any Cardiologists you see if applicable

Are you taking any weightloss medications (Ozempic/Wegovy/Saxanda) *

YesNo

Please provide details of medication, dosage and frequency: *

Do you smoke tobacco or vape? *

YesNo

If yes, please provide how often you smoke and amount below: *

Do you drink alcohol? *

YesNo

If yes, please provide below how often you drink and how many standard drinks: *

What is your weight in kgs? *

What is your height in cms? *

BMI

Please list all current medications and supplements

Name of medication and dosage

Cancellation Policy

If appointments are cancelled within 48 hours of the scheduled appointment, a $100 cancellation fee will be charged. If an appointment is cancelled within 24 hours or patients do not attend, a $100 cancellation fee will be charged. No further appointments will be made until the fee is paid. If the patient is a Workcover/DVA or ADF patient, this cancellation fee will be paid by the patient personally and not covered by the third party.

I understand and agree. *

Zero Tolerance Policy

The practice of Dr Subash Balakrishnan (“this Practice”) has a ZERO TOLERANCE approach to any verbal, aggressive and violent abuse and behaviour towards our Drs, staff or other patients. Our Drs and practice staff have a right to care for others without fear of being attacked or abused.

To successfully provide these services a mutual respect between all the staff and patients must be in place.

Dealing with people who are abusive or aggressive towards our staff and our patients, takes us away from caring for you. All our staff aim to be polite, helpful, and sensitive to all patients’ individual needs and circumstances.

The staff understand that patients who are in a lot of pain do not always act in a reasonable manner and will take this into consideration when trying to deal with a misunderstanding or complaint.

However, aggressive behaviour, be it violent or abusive, will not be tolerated. Abusers will be required to leave the Practice and be asked to transfer their care elsewhere. In extreme cases, including refusal to leave the Practice will result in the police being called.

We have the right to refuse treatment and take further action against anyone who threatens the safety of our staff and our patients.

In order for the practice to maintain good relations with their patients the practice would like to ask all its patients to read and take note of the occasional types of behaviour that would be found unacceptable:

Using offensive language or swearing at practice staff
Using a raised voice or yelling in an angry manner at practice staff
Any physical violence towards any member of the Practice Team or other patients, such as pushing or shoving
Verbal abuse towards the staff in any form including verbally insulting the staff
Racial abuse and sexual harassment will not be tolerated within this practice
Persistent or unrealistic demands that cause stress to staff will not be accepted. Requests will be met wherever possible and explanations given when they cannot.
Causing damage/stealing from the Practice’s premises, staff or patients
Obtaining drugs and/or medical services fraudulently

We ask that you agree to these terms prior to your initial appointment so you are aware of the outcome of undesired behaviour.

I understand and agree *

Privacy Consent

I give my consent to Dr Subash Balakrishnan to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Dr Subash Balakrishnan and their practice as may be requested. This is in line with the National Privacy Act, updated 1st November 2010. I authorise Dr Subash Balakrishnan to include the medical practitioners or other specialists I have named in patient correspondence, in the form of reports, letters or any other means as deemed applicable by Dr Subash Balakrishnan. For more information view our Patient Information Privacy Statement (further information below).

Signature *

Clear

Date *

Patient Information Privacy Statement Introduction Our practice is committed to best practice in relation to the management of the information we collect. This practice has developed a policy to protect patient privacy in compliance with the Privacy Act 1988 (Cth) (‘the Privacy Act’). Our policy is to inform you of:

the kinds of information that we collect and hold, which, as a medical practice, is likely to be ‘health information’ for the purposes of the Privacy Act;
how we collect and hold personal information;
the purposes for which we collect, hold, use and disclose personal information;
how you may access your personal information and seek the correction of that information;
how you may complain about a breach of the Australian Privacy Principles and how we will deal with such a complaint;
whether we are likely to disclose personal information to overseas recipients;
we will obtain your written permission prior to disclosure of your
personal information to any overseas entity or recipient.

What kinds of personal information do we collect? The type of information we may collect and hold includes:

Your name, address, date of birth, email and contact details
Medicare number, DVA number and other government identifiers, although we will not use these for the purposes of identifying you in our practice
Other health information about you, including: notes of your symptoms or diagnosis and the treatment given to you; your specialist reports and test results; your appointment and billing details; your prescriptions and other pharmaceutical purchases; your genetic information; your healthcare identifier; any other information about your race, sexuality or religion, when collected by a health service provider

How do we collect and hold personal information? We will generally collect personal information:

From you directly when you provide your details to us. This might be via a face to face discussion, telephone conversation, registration form or online form.
From a person responsible for you.
From third parties where the Privacy Act or other law allows it - this may include, but is not limited to: other members of your treating team, diagnostic centres, specialists, hospitals, the My Health Record system, electronic prescription services, Medicare, your health insurer, the Pharmaceutical Benefits Scheme.

Why do we collect, hold, use and disclose personal information? In general, we collect, hold, use and disclose your personal information for the following purposes:

To provide health services to you.
To communicate with you in relation to the health service being provided to you.
To comply with our legal obligations, including, but not limited to, mandatory notification of communicable diseases or mandatory reporting under applicable child protection legislation.
To help us manage our accounts and administrative services, including billing, arrangements with health funds, pursuing unpaid accounts, management of our ITC systems.
For consultations with other doctors and allied health professional involved in your healthcare.
To obtain, analyse and discuss test results from diagnostic and pathology laboratories.
For identification and insurance claiming.
If you have a My Health Record, to upload your personal information to, and download your personal information from, the My Health Record system.
Information can also be disclosed through an electronic transfer of prescriptions service.
To liaise with your health fund, government and regulatory bodies such as Medicare, the Department of Veteran's Affairs and the Office of the Australian Information Commissioner (OAIC) (if you make a privacy complaint to the OAIC), as necessary.

How can you access and correct your personal information? You have a right to seek access to, and correction of the personal information which we hold about you. For details on how to access and correct your health record, please contact our practice as noted below under ‘Contact Details’: We will normally respond to your request within 30 days. How do we hold your personal information? Our staff are trained and required to respect and protect your privacy. We take reasonable steps to protect information held from misuse and loss and from unauthorised access, modification or disclosure. This includes:

Holding your information on an encrypted database.
Holding your information in secure cloud storage (you can explain whether this information is encrypted or what other security measures are taken with third party storage).
Our staff sign confidentiality agreements.

Privacy-related questions and complaints If you have any questions about privacy-related issues or wish to complain about a breach of the Australian Privacy Principles or the handling of your personal information by us, you may lodge your complaint in writing to (see below for details). We will normally respond to your request within 30 days.

If you are dissatisfied with our response, you may refer the matter to the OAIC:

Phone: 1300 363 992

Email: enquiries@oaic.gov.au

Fax: (02) 9284 9666

Post: GPO Box 5218,
Sydney NSW 2001

Website: https://www.oaic.gov.au/privacy/privacy-complaints

Anonymity and pseudonyms The Privacy Act provides that individuals must have the option of not identifying themselves, or of using a pseudonym, when dealing with our practice, except in certain circumstances, such as where it is impracticable for us to deal with you if you have not identified yourself. We have determined that it is largely impracticable for our practice to deal with patients anonymously or via a pseudonym. The provision of medical services is likely to be impacted, and billing via Medicare or a health insurer where applicable is likely to be impracticable.

Therefore, we require that you use your name and not a pseudonym.

Overseas disclosure We may disclose your personal information to the following overseas recipients:

Any practice or individual who assists us in providing services (such as where you have come from overseas and had your health record transferred from overseas or have treatment continuing from an overseas provider).
Anyone else to whom you authorise us to disclose it.

Updates to this Policy This Policy will be reviewed from time to time to take account of new laws and technology, changes to our operations and other necessary developments.