Patient Registration Form

Patient form

Patient's Information

Title

Given Name

Surname

Date of Birth

Mobile

Home Phone

Address

City

State

Postcode

Next of Kin Name

Relationship to Patient

Phone/Mobile

Medicare Number

Reference Number

Expiry Date

Pension Card (CRN)

Expiry Date

Health Fund

Membership Number

DVA

Color

General Practitioner (GP) Information

Name

Phone/Mobile

Address

City

State

Zip Code

Consent Form for the Use of Information Technology & Artificial Intelligence (AI) in Medical Consultations

Your privacy and the security of your personal and health information are our highest priorities. This form seeks your informed consent for the use of artificial intelligence (AI) technology during your medical consultations.

Purpose of AI Use

Your clinician may use AI-powered software during your consultation to record and transcribe your conversation.
The transcribed notes will be reviewed and verified by your clinician before being added to your official medical records.
This technology allows your clinician to focus fully on your consultation, actively listening to your concerns, answering your questions, and providing the best possible care, rather than being distracted by taking notes.

Confidentiality and Data Security

All transcriptions, notes, and letters are securely stored and accessible only to authorised personnel at your clinic for a limited time, as determined by your clinician.
Your personal and medical information is handled with strict confidentiality, in full compliance with the Privacy Act 1988 and Australian Privacy Principles.
Your data will never be shared with unauthorised third parties, used for AI training, sold, or used for marketing purposes.

Medicolegal Considerations

The AI system does not replace clinical judgement or decision-making. Your clinician remains fully responsible for the accuracy and appropriateness of your medical records.
The recorded and transcribed information forms part of your legal medical records and may be used for clinical decision-making, audits, or legal purposes if required.
You retain the right to request access to your medical records as per standard privacy regulations.
If you have any concerns about the use of AI in your consultations, you are encouraged to discuss them with your clinician.

Your Rights and Consent

You have the right to decline or withdraw your consent at any time, without any impact on your ongoing care.
If you withdraw consent, AI will no longer be used in your consultations, but previously recorded notes will remain part of your medical records as per legal and professional requirements.
By signing below, you confirm that:
You have read and understood this consent form.
You have had an opportunity to ask questions and receive clarification from your clinician.
You voluntarily consent to the use of AI software during your consultations for transcription and medical documentation purposes.

For more information on how we collect, use and protect your personal information, please read our Privacy Policy.

I have read and understood the “Consent Form for the Use of Information Technology & Artificial Intelligence (AI) in Medical Consultations”. I voluntarily consent to the use of AI transcription software during my consultation for medical documentation purposes.

I authorise the billing of consultation fees to my private health insurance or Medicare rebate, where applicable, for services provided as an inpatient, outpatient, or via Telehealth (phone or video). I acknowledge that any outstanding fees not covered by my insurer or Medicare remain my responsibility. I also authorise the release of my health information to other healthcare providers for the purpose of continuing care by another provider and for receiving care at the health facility. Where a service is bulk billed, I assign my right to the Medicare benefit(s) payable to the health professional (or Approved Pathology Practitioner) providing the services, and accept the Medicare benefit as full payment.

Signature

Signed by:

Date: 10/10/2026