Dr Carolyn Marshall – Paedatrician – New Patient Registration Form Dr Carolyn Marshall's Registration Form Paediatrician Dr Carolyn Marshall's Registration Form Paediatrician Step 1 of 5 20% Dr Carolyn Marshall- Registration From PaediatricianPlease notify reception if name of Paediatrician is incorrectName of Patient* First Last D.O.B. of the Child* DD slash MM slash YYYY Gender*MaleFemaleOtherYour Child’s Nationality*Country of Birth*Do you identify as Aboriginal / Torres Strait Islander?* Yes - Aboriginal Yes - Torres Strait Islander Yes - Both Aboriginal & Torres Strait Islander No Do you require an interpreter?* Yes No Preferred Language*Residential Address* Street Address Suburb State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman 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 RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall 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 Postal Address*Same as aboveDifferent Postal AddressPostal Address (If different) Street Address Suburb State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman 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 RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall 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 Primary Mobile Phone*Email* Medicare Number*Ref Number (next to name)*123456789OTHERExpiry Date*month/year Name of Mother and Father or if applicable the legal guardians / caregiversParent / Guardian 1Please note that invoices will be issued in this person’s name (with the child as the patient) and the Medicare rebate will be issued to Parent/Guardian 1.Name First Last D.O.B* DD slash MM slash YYYY Relation to child*Medicare Ref*Legal guardian* Yes No Phone Number*Parent / Guardian 2Name First Last D.O.B DD slash MM slash YYYY Relation to childMedicare RefLegal guardian Yes No Phone NumberSiblings of the patientNameAgeNameAgeNameAgeNameAgeNameAgeNameAgeWhere did you hear about Cairns Doctors? Care and Legal StatusAre there any third parties, e.g., Child Safety, involved in the legal care or custodianship of the child?* Yes No If yes, please answer the questions below.OrganisationContact phone number of the organisationContact PersonAre there any court orders relating to the care or custodianship of the patient?* Yes No If yes, please provide a copy. Court OrderMax. file size: 512 MB. OUR PRIVACY POLICYAll information collected in this practice is treated as sensitive information and strictly confidential. To protect your privacy Cairns Specialist on Barr St operates in accordance with the Australian Privacy Act, its amendments, and the Australian Privacy Principles. For more information please see www.oaic.gov.au/privacy-law/privacy-act. We use the information you provide us to better manage your health care. You can help us maintain the accuracy of your information by advising Cairns Specialist on Barr St of any changes to your address and phone numbers. Certain information may be disclosed to other health services involved in supporting your health management (e.g. pathology and radiology providers, immunisation registers, specialist, community health referrals, etc). If you have any questions or concerns about how we manage your personal health information, or need access to your records, please ask our friendly team members or your doctor. Since 2019 all Australians have the "My Health Record' automatically created if you have not opted out: http://www.myhealthrecord.gov.au. The full Cairns Specialist on Barr St Privacy Policy can be found here: https://cairns-doctors.com.au/practice-policies/. Test results For privacy reasons, it is the policy of Cairns Specialist on Barr St to not give out any test results over the phone if you call us. We will let you know if your Paediatrician needs you to make an appointment to discuss the results of any recent tests you have had done.Quality Assurance We welcome any comments or suggestions and will take these seriously. If you have any complaints, please contact us to discuss these directly with your specialist or the Practice Manager. Emails and Sharing Information consent We use emails only to exchange relevant information with you, and other services you agreed to, e.g., school, support agencies, allied health etc. Sharing information can include the clinic letter, medical certificates, disability verifications, and my include sensitive information like a presumed or proven diagnosis to facilitate multidisciplinary shared care. While we take all reasonable steps to guarantee your privacy, these emails are not encrypted. Risks included but not limited to interception of emails during transit or unintentionally sending it to a wrong person. If you agree to the use of emails, we ask you and third parties to email us first to: paeds@cairns-doctors.com.au. This means you need to give our email and your consent to contact Dr Carolyn to the third party. This reduce the risk of incorrectly typing the wrong email address. You can withdraw your consent in writing any time. Emails are only for sharing information, not for discussing any medical concerns, requesting prescriptions or to change or request an appointment. You need to call us, and our receptionist will be happy to help with your request. Emails are only for sharing information, not for discussing any medical concerns, requesting prescriptions or to change or request an appointment. You need to call us, and our receptionist will be happy to help with your request. Do you consent to share information per email(If NO, we will only use standard postal mail or fax)Do you consent to share information per email* Yes No Sharing Information with Third PartiesDo you consent us to share information with third parties other than yourself and the referring GP/Doctor? If yes please specify with whom (e.g. School, SLT/OT Therapist, Psychologist, NDIS, Cairns Base Hospital, Child Youth Mental Health Service, Support workers, Act for Kids).Do you consent us to share information with third parties other than yourself and the referring GP/Doctor?* Yes No If yes to whom (you must specify each service e.g. School, Speech and Occupational therapist, Psychology, other Doctors etc you consent to)Policy ConfirmationPolicy Confirmation*I have read and understand the above information. I received the ‘Pediatrician Welcome Information’ with the fee list, cancellation policy, separated parent and legal guardianship policy. I received the ‘Telehealth video and phone consultation policy’. I understand that: - The child must be present for all appointments, including face-to-face, telehealth video and phone consults - It is my responsibility to inform the other parent/legal guardian about all appointments, invite them to attend, and to provide feedback if there is no court order otherwise - It Is my responsibility to make sure there is a valid GP referral for each visit - I am responsible for the payment of fees at the time of the appointment - The $100 booking-fee is not refundable should I change my mind and decide the initial appointment is not required anymore and if I don’t show for the initial appointment there will be additional charges - If I am a bulk billed patient, I agree for Medicare benefit to be assigned to Dr Carolyn for all in-person and for all telehealth appointments I had the opportunity to ask questions and clarify any concerns. Yes*Parent / Guardian*Full nameParent / Guardian Signature*Date* DD slash MM slash YYYY Allergies, sensitivitiesDoes your child have any allergies or sensitivities – in particular to any medications? Please write "NIL" if none knownAllergies / sensitivities*Reaction*Current Medications of your childPlease list any tablets, suspensions or inhalers your child is taking (please include vitamins and any ‘natural’ remedies) Please write "NIL" if none.Name of medicationDoseName of medicationDoseName of medicationDoseName of medicationDosePast Medical History of your childPlease write "NIL" in none knownDetailsYearFamily Medical HistoryMotherFatherSiblingsOther Close RelativesPregnancy and Birth HistoryPregnancyGestational age at birthBirth weight / length / head circumferenceAny post-natal complications / concernsDevelopmental historyAny developmental concerns you had in the past for your childPlease write "NIL" if unknownLifestyleDaycare / Kindergarten / School (e.g. any concerns reported from teachers)Friends (e.g. does your child socialise well, has good friends and a supportive peer group)Out of school activities / hobbies / sports / interestsIs there anything else you think Dr Carolyn should know?
