Coastal Gastroenterology

Coastal Gastroenterology

Dr Oliver Waters Rooms — Medical Questionnaire and Consent

Please complete all sections before your appointment. Your answers help us prepare for your consultation and any procedures, and are handled in accordance with our privacy policy.

Section 1

Patient details

Please enter your name exactly as it appears on your Medicare card.

Section 2

Relevant personal information

Medicare, private health insurance and concession card details.

Section 3

Social history

Section 4

Health information for booking of procedures

It is important to complete this section.

Section 5

Previous medical testing / procedures

If you have had any recent pathology performed, please indicate the relevant pathology providers.

If you have had any relevant radiology in the past 5 years, please indicate the relevant radiology provider.

Referrals, results or letters. Max 5 files.

Section 6

Consent for collection of personal information

Please read through this information carefully.

Privacy and consent information

I consent to the release of my history, pathology and other medical test data (my medical data) to be made available to my treating medical practitioners at Coastal Gastroenterology for the purpose of providing care to me. I consent to the release of my medical data by participating providers that relates to my ongoing care at Coastal Gastroenterology to be made available to my treating medical practitioners at Coastal Gastroenterology for the purpose of providing care to me.

I understand that my personal information may also be used for administrative purposes (such as verifying my identity with participating providers) to ensure the correct medical data is released. I understand the reason why my medical data and personal information will be collected by my treating medical practitioners at Coastal Gastroenterology. I am aware of my right to access my medical data and personal information, except in rare circumstances where access might legitimately be withheld. I understand I will be given an explanation in those rare circumstances.

I understand that, if my medical data and personal information is to be used for any purpose other than set out in this consent form, my further specific consent is required. I understand my medical data will be stored for a minimum of seven years from the time of my treating medical team's last interaction, in accordance with the relevant medical records storage legislation and guidelines. The consent will remain valid from my last interaction with Coastal Gastroenterology as evidenced by my treating medical team to deliver care to me until I withdraw my consent.

You can decline to have your health information used in all or some of the ways outlined above, but this may influence the ability to manage your health care and to provide the best outcome for you.

Recording of consultations

For the purposes of documentation and to ensure accurate record-keeping, your consultation may be recorded. This recording is for your Gastroenterologist's use only. These recordings are deleted after all information required has been obtained. We use Lyrebird to automate our paperwork during consultations, which enables your consultant to pay better attention to you. To find out more, visit lyrebirdhealth.com/au/patient.

Privacy policy

Coastal Gastroenterology and your health practitioner/s aim to protect the privacy of health information in accordance with the Gastroenterology Specialist Care Privacy Policy and the Health Records Act 2001. A copy of this privacy policy can be obtained at gastrosc.com.au.

Section 7

Billing

Patient fees are billed privately (not bulk billed) except at individual practitioner discretion. All accounts are payable IN FULL on the day or before.

In person payment via credit/debit cards only (no cash). Video appointment payment is made prior to your video consultation via an online payment service — we will send you a link to do this two days before your scheduled consultation.

Where applicable, paid accounts will be submitted to Medicare for a rebate on your behalf (provided you have a current referral and Medicare card).

We are a NO GAP provider for all endoscopic procedures (with the exception of EMR *32230). This means that unless you have an excess to pay on admission to hospital, you will be fully covered and should have NO out of pocket expense.

We also endeavour to use NO GAP anaesthetists for all of our procedures BUT cannot guarantee that there will be no gap to pay with your scheduled anaesthetist. If you are not sure whether you have an excess to pay, you will need to check this with your health fund.

A cancellation fee may be charged for failing to attend your appointment.

Section 8

Consent and signature

I confirm that the above information is CORRECT and ACCURATE at the time of signing.

Draw your signature in the box below.

Not signed yet.

Coastal Gastroenterology — Dr Oliver Waters Rooms · My completed forms · Staff access