New Patient Form

PRIVATE & CONFIDENTIAL

To prepare for your upcoming medical appointment, please complete all required fields and submit the form at least 72 hours.
This form is required prior to your appointment. This form will be securely kept in your patient files.

You can partially complete and SAVE, and when complete please click SUBMIT
If you have any queries or require assistance with this form, please speak to a Telecare Coordinator on ph 0390524872

PATIENT Details

Sex assigned at birth *

MaleFemaleOther

Other Sex

Gender Identity

Other Gender

First Name *

Last Name *

Date of Birth *

Is the patient 17 years of age or younger *

YesNo

Knowing your cultural background can help us provide healthcare that meets your individual needs. Are you Aboriginal or Torres Strait Islander origin?

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNone of these

Specialty you have been referred to ****IMPORTANT*** Please ensure you've selected the CORRECT Speciality as this will affect the rest of this form - if you're unsure, please speak with a Telecare Booking Coordinator phone 03-9052-4872

Is this medical appointment/s under Work Cover Insurance?

YesNo

WorkCover Insurer Name

Case Number

Upload your WORK COVER approval letter

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VICTORIA PATIENT: Is this appointment under a TAC Claim

YesNo

Upload your TAC approval letter

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This is required to confirm TAC will fund your appointment. If we do not receive confirmation, fees will apply for your appointment

Is this appointment for mental health support or diagnosis? *

Yes - Never been diagnosedYes - Previously been diagnosedNo

Where did you hear about our service? *

Contact Details

Mobile Phone *

Home Phone

Postcode *

Street Address

City / Suburb

State

This is also my nominated postal address *

YesNo

Postal Address

Email *

Parent/Guardian Email *

Are the parents *

living togetherseparatedone surviving parent

MOTHER's Name *

Date of Birth (for Medicare Rebate purposes) *

Age

MOTHER's mobile phone *

Occupation *

FATHER's Name *

Date of birth (for Medicare Rebate purposes) *

Age

FATHER's mobile phone *

Father's occupation *

Guardian's Name *

Guardian's DOB (for Medicare purposes) *

Age

Other guardian/s? *

YesNo

Full name

Mobile phone

Occupation

Siblings? *

YesNo

Sibling name

Sibling Age *

Additional Siblings?

YesNo

Additional Siblings?

YesNo

Additional Siblings?

YesNo

Next of Kin and/or Alternate Contact Person NAME *

Next of Kin and/or Alternate Contact's MOBILE NUMBER *

Other NOK *

Will this person assist the patient with appointments? *

YesNo - The patient will arrange appointmentsSomeone else will help

Consent to contact your Next of Kin regarding your appointment/s if we cannot reach you; Medical information is not discussed with this person

Consent to contact your Next of Kin in case of emergency or reasonable belief there is risk of harm to yourself or others; Medical information may be disclosed to this person

Name of carer and/or a 'support' person *

Mobile number (must be different to the patient's) *

Is your Next of Kin your nominated "Collateral" person *

Yes - my Next of Kin will join as my CollateralNo - I'd like to invite someone else

Collateral Name *

Collateral contact number *

Current Teacher's Name

Teacher or school Email address

Family Doctor (If different from referring doctor)

YesNo

Medical History

Allergies

Current medication

Is Immunisation up to date? *

YesNo

Has the patient previously seen a paediatrican *

YesNo

Approximate Date

Relevant Medical Records

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Medical report, school reports, diagnostic reports etc

Relevant Medical Records (additional)

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Medical report, school reports, diagnostic reports etc

PHOTO of the area/s of concern (From the last 12 months) *

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Photos are MANDATORY to proceed with a Dermatology telehealth appointment

PHOTO 2 ADDITIONAL (Optional)

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Photos are MANDATORY to proceed with a Dermatology telehealth appointment

PHOTO 3 ADDITIONAL (Optional)

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Photos are MANDATORY to proceed with a Dermatology telehealth appointment

PHOTO 4 ADDITIONAL (Optional)

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Photos are MANDATORY to proceed with a Dermatology telehealth appointment

Any other relevant information you'd like your specialist to know

Preferred Local Pharmacy

Do you have a preferred local pharmacy for obtaining medications?

YesNo

Medicare

Do you use a different name on your Medicare card?

YesNo

Please write the alternate name & surname printed on your Medicare card

Medicare First Name

Medicare Surname

Medicare Card No. *

Reference No.(This is the single digit number next to your name on the Medicare card)

Expiry

Parent/Guardian Medicare Card No. *(Guardian details are required for patients 17yrs and under)

Parent/Guardian Ref No.(This is the single digit number next to your name on the Medicare card)

Guardian Card Expiry

Do you have a Dept. of Veteran's Affairs card?

YesNo

DVA Card Type

GoldWhiteOther

DVA No.

As a DVA Gold Card holder, your appointment will be bulk-billed;

As a DVA White Card holder, please confirm you are covered via DVA’s MyService app, or email nlhc@dva.gov.au, or call DVA on 1800 VETERAN (1800 838 372) prior to booking, and confirm with us to enjoy bulk bill services;

We will still collect credit card details for the Late Cancellation (within 48 hours) / No Show policy - to avoid this fee, please kindly advise Telecare if you're unable to attend your appointment at least 48 hours prior to your appointment;

As a DVA LILAC, ORANGE or BLUE card holder, your appointment/s are subject to private fees.

ADHD Medication Waiver

This informed consent and waiver is provided to you in relation to the prescription of psychostimulant medications. You must acknowledge and agree to the following terms before such medications may be part of a treatment plan.

Where this Form refers to 'we', 'us', 'our' as Telecare Australia, and also includes our personnel, including all practitioners on our website or portal.

Where the Patient is a minor, or is otherwise unable to complete this Form, the Authorised Representative set out in the table above may sign this Form on behalf of the Patient and, in such cases, you will mean the Authorised Representative. You warrant and agree that, if you are completing and signing this Form on behalf of the Patient, that you have the required authority to do so.

This informed consent and waiver shall remain in effect for the duration of the Patient's treatment with the prescribed psychostimulant medication, unless revoked or amended in writing by the Patient or Authorised Representative.

Prescription of the Medication

You agree to follow your treating medical practitioner’s instructions regarding the proper use, dosage, frequency, and duration of the prescribed psychostimulant medication. You understand that failure to comply with these instructions may result in adverse effects or diminished therapeutic benefits.

You confirm that you have read and understood the information provided to you regarding the prescribed psychostimulant medication, including the potential risks, benefits, and side effects associated with their use.

You understand that you have the right to withdraw your consent for the treatment with psychostimulant medication at any time. To do so, you must provide written notice to your treating medical practitioner, and you agree to follow any instructions provided by them regarding the safe discontinuation of the medication. In the event of an emergency, where you cannot contact your treating medical practitioner, you agree to seek appropriate medical advice from your nearest open medical clinic or emergency room.

Use of Recreational Drugs

You confirm that the Patient is not currently using any recreational drugs. You acknowledge and agree that using recreational drugs while taking prescribed psychostimulant medications can lead to adverse health consequences.

You acknowledge that you have had the risks associated with taking psychostimulant medications explained to you, including the potential for abuse, dependence, and other side effects.

You acknowledge and agree that it is your responsibility to ensure you do not use any recreational drugs while taking the prescribed psychostimulant medication.

Liability

To the maximum extent permitted by law, we (and our personnel, including any medical practioners) will not be liable for any harm or injuries the Patient may suffer as a result of not following recommendations regarding the use of psychostimulant medication, unless we are negligent.

Emergency Services

You acknowledge and agree that we may call emergency services if (at our sole discretion) we have the reasonable opinion that the Patient is putting themselves or a third party at risk of harm.
Telecare is not an emergency service. I n the event of an emergency where you are unable to contact your treating medical practitioner, you will seek appropriate medical advice from the nearest open medical clinic or emergency room.

I acknowledge and agree that I have read, understood, and agree to the terms outlined in this waiver.

Signed by the patient or Signed for and on behalf of the Patient by their Authorised Representative who warrant that they have the proper authority to do so

Paediatric development and behavioral assessments

Thank you for choosing one of Telecare's paediatricians who specialise in development and behavioural assessments for your child. We want to make sure you understand what to expect during the assessment process.

Multi-Step Procedure: The assessment is a detailed process with several steps. It might take multiple appointments to fully evaluate your child's condition.
Review of Notes and Results: With consent from the parents/carers, our paediatricians will carefully review various notes and investigation results, like medical records, previous assessments, and relevant tests. This helps them understand your child's medical, developmental, and behavioural history. If you have any reports that may be relevant, please send them through before the appointment.
Collaboration with Others: To make an accurate diagnosis, our paediatricians work with other healthcare professionals, educators, and caregivers involved in your child's care. This collaboration provides a better understanding of your child's unique situation.

Please remember that a thorough assessment may take time and careful consideration. We appreciate your patience as we work towards the best outcome for your child. We aim to provide the best care and accurate diagnoses for your child's needs. If you have any questions or concerns, our team is here to support you.

Yes, I agree *

Payment Details and Cancellation Policy

Prepayment:

You accept the Medical Consultation fee/s provided to you during the booking process and will contact Telecare to clarify fees and payment options if required and at least 72 hours prior to an appointment/s. You understand that Telecare will collect your card details via Eway, an Australian based secure payment pathway. You can request to update or remove your details at any time in writing by emailing: admin9@telecare.com.au

You agree your payment method will have sufficient funds to pay the full fee, and consent to Telecare using your collected card details for payment of any follow up consults you book and attend. Your payment will be processed 72hrs prior to your appointment.

If a payment is declined, you may be subject to a late payment adminstration fee.

Cancellation/Missed appointments:
Please understand that our specialists (and your GP where applicable) have reserved their time for you. If you must cancel your appointment, we respectfully request 48 hours notice so we have time to organise another patient who needs this service. Missed appointments, or appointments cancelled without valid medical reason within 48 hours of the appointment will incur a fee ($150).

Surcharge:
Credit card surcharge applies (1.7% + 20c per transaction)
Contact our rooms for bank transfer details. Electronic funds transfers must be received into Telecare's account no later than 72 hours prior to your appointment

Yes, I agree. *

Cardholder is the patientCardholder is not the patient

I, the Cardholder, consent to the Cancellation policy and Payment of Fee *

Signature of Cardholder *

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If you receive an error and/or cannot lodge your form, please call Telecare ph 03-9052-4872 and speak to our team for assistance - We may SMS/call you if your form is not received by 72hrs prior to your appointment - *Without a complete form, your appointment may be cancelled*

Patient Consents

I understand that Telecare and Telecare specialists are unable to provide any emergency assistance, including mental health crisis or emergency (acute suicidal thoughts, recent suicide attempt, experiencing domestic violence, experiencing uncontrolled aggressive or threatening behaviour). If there is a medical emergency, I will reach out to my GP or go to my nearest hospital or the local mental health service or the crisis team, or call 000 for emergency services, we will return your care to your GP to support you with alternative local care in such case. *

I understand, in most cases, Telecare psychiatrists can only provide psychiatric assessment for advicee on diagnosis, medication or treatment options to guide your referring GP to prescribe and manage any recommended medication. It is your responsibility to ensure that your GP will enact your treatment plan (which includes initiating the recommended medication) and provide the necessary follow-up care. Our clinicians can work closely with your GP to ensure this happens. Telecare psychiatry services are not meant to be for ongoing care.

Ongoing counselling and mental health support may be available with a psychologyist or psychotherapist at Telecare (please speak with your GP and your Telecare psychiatrist if you are eligible for a care plan) *

I agree, that during the telehealth consultation with Telecare, photo IDs might be validated by the clinician, based on telehealth best practice guideline, this is required for identification of the correct patient, so please bring your photo ID with you when you join the telehealth consult room.

If clinically required, a screen shot may be taken, with your verbal agreement and knowledge, to capture your photographic image. The screenshot will be stored confidentially within your electronic medical record and handled in accordance with the Privacy Act 1988 (Cth).

Please upload or take a picture of your photo ID for the clinician to validate your identity during the telehealth consultation

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Obtaining medical information

As part of providing a clinical service to you, Telecare's specialist or allied health provider will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the assessment and treatment that is conducted.

Purpose of collecting and holding information

The information is gathered as part of the assessment and is seen only by your provider and Telecare staff. The information is retained to document what happens during sessions and enables the provider to provide a relevant and informed clinical service.

Access to Client Information

At any stage you as a client are entitled to access to the information about you kept on file unless the relevant legislation provides otherwise. The provider may discuss with you appropriate forms of access.

Confidentiality

All personal information gathered by the provider during the provision of the service will remain confidential and secure except where:

It is subpoenaed by a court, or
Failure to disclose the information would place you or another person at serious risk/danger/harm; or
To provide a written report to another professional or referring agency eg. a GP to discuss the material with another person, eg. a parent or if disclosure is otherwise required or authorised by law. It is a Medicare requirement that progress reports be sent to the referring GP.

Consent provided *

Yes, I agree

SIGNATURE

I understand that Telecare and Telecare specialists are unable to provide any emergency assistance. If there is an emergency I will reach out to my GP or go to my nearest hospital or the local mental health service or the crisis team, or call 000 for emergency services *

I confirm the above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature *

Draw signature|Type signatureClear

Today's Date *

Contact Information

How Telecare Manages Your Information

For any enquiries please contact us on

Physicians and Paediatrics: 03 9052 4872

Psychiatry and Psychology: 03-9034-9950

Veterans: 03-6153-0066

Email: admin@telecare.com.au

Live chat: https://www.telecare.com.au/

Access Telecare's Privacy policy here https://www.telecare.com.au/privacy-policy

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