02 97098477
office@drahmadalrubaie.com.au
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Dr Ahmad Alrubaie
Dr Ahmad Alrubaie
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Patient Information Form

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Patient Information:
Title:
Given Name(s): *
Surname: *
Date of Birth: *
Address:
Suburb:
Postcode:

Please provide at least two (2) telephone numbers for contact purposes

Home Phone:
Work Phone:
Mobile: *
Email:
Occupation:
Gender:
Country of Birth:
Marital Status:
Language(s) Spoken at Home:
Medicare and Insurance details:
Medicare number: *
Reference number: *
Expiry:
Veteran Affairs number:
Pension Card #:
Private Health Fund:
Membership Number:
Date Commenced:
Next of Kin / Emergency Contact 1:
Name:
Emergency Tel:
Relationship to you:
Is this person authorised to discuss your medical information?
Next of Kin / Emergency Contact 2:
Name:
Emergency Tel:
Relationship to you:
Is this person authorised to discuss your medical information?
Referring Doctor Details:
Referring Doctor Name:
Phone:
Fax:
Clinic Name:
Suburb:
Is your referring doctor also your usual GP?
Usual Doctor & GP Details:
GP Doctor Name:
Phone:
Fax:
Clinic Name:
Suburb:
Preferred location for procedure(s) - you may choose more than one:

Consent to Collect Patient Information

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 deta·i1s 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 treating doctors and specialists outside this medical practice as advised by you.

    To comply with the Privacy Act 2001, all patients need to provide consent for the above aspects of their medical care. Staff are bound by strict confidentiality requirements. Please be aware that we only keep scanned computer generated copies of your original documentation. If you require return of your original documents please advise reception staff at the time of your appointment. All non-returned original documents will be disposed of securely within 24 hours of your appointment.
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Please sign the form using the signature area below:
Patient Signature *
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Full Name: *
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Dr Ahmad Alrubaie
Locations:
Bankstown
58 Gallipoli Street, Bankstown NSW 2200
(02) 9709 8477
(02) 9709 8477
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Bowral
93 – 95 Bowral Street , Bowral 2576
(02) 4862 9450
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