New Patient Form Dr Su-Min Wong

Please list any other treatment providers you are/have seen for your current pain/injury/reason for consult:

MEDICAL EXAMINATION AND INFORMATION PRIVACY POLICY

You have been referred to attend this specialist clinic to be medically assessed and managed by Dr Su-Min Wong.Dr Wong is a Rehabilitation Medicine Physician who specialises in treating those affected by function limiting physical orcognitive conditions due to illness or injury. This may include musculoskeletal disorders, occupational injuries, pre andpost joint surgery, post trauma, brain injury, spinal cord injury, stroke, and other complex neurological orneurodegenerative disorders.Your initial assessment may take between 30 to 60 minutes ( or more), depending on the complexity of your condition. Itis encouraged, but not necessary, that you have someone to accompany you for the consultation. The consult would entaila detailed history from you, followed by a detailed, targeted physical examination.In order to best support your care, contact and correspondence with your other treating health professionals is usuallyrequired. To allow this, you are asked to sign a consent form for exchange of information with your other healthproviders. If you have any concerns or specific exclusion clauses, please note this on your form prior to your firstappointment, or notify staff of any changes at subsequent reviews.This practice is committed to protecting your privacy in accordance with national Australian Privacy Principles (APPs),which were introduced into the Privacy Act 1988 (Cth) in March 2018. The type of information we may collect and holdincludes (but not limited to):• Your full name, address, date of birth, employment details, email/contact details• Medicare number, DVA number and other government identifiers,• Health Insurance details• Other health information, including: notes of your symptoms or diagnosis, specialist reports, test results, appointment &billing details, prescriptions, family history and other information (e.g. race).The information is stored on an encrypted electronic medical record, which is accessible only to staff on a “need to know”basis. Staff and contractors are bound by confidentiality agreements. The practice has document retention and destructionpolicies.Signed Consent:I consent to the handling of my information by this practice for the purposes and in the manner outlined above. I alsounderstand and consent to the relevant physical examinations. I understand that I am not obliged to provide anyinformation requested of me, but failure to do so might compromise the quality of health care and treatment I receive.