Specialist Colorectal Surgery
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Phone: 9793 2687   Fax: 9793 0090

Patient registration form

You can complete this form online prior to coming to your appointment.  Don't forget to tell our receptionist that you have done this, so you don't need to complete another registration form.
Your information is confidential and will be received directly by South East Colorectal.
Your privacy is important to us and your information will not be shared with any third party without your permission
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    DETAILS

    Some people like to be known by a name other than their "official" name. Please let us know if you like to use another name.
    If you do not have an email address, just write N/A
    Sometimes we sent patients copies of correspondence or reports. We can email these to you in a .pdf document, with your permission, rather than a hard copy letter.
    This can be a relative or a friend, preferably in Victoria.
    Your emergency contact person can be your partner or spouse, a relative, a friend, even a neighbour. As long as we have someone we can contact in case of emergency.
    It helps if we have more than one means of contacting you.
    This could be your GP or another specialist, or you may have have been referred through the hospital. Please give us as much detail as you can.
    If you have been referred by another specialist or through the hospital, please tell us who your usual local doctor (GP) is. This will help us ensure correspondence goes to everyone in your health team. If your GP has referred you, just type "as above".
    You may bring a family member or a friend to interpret for you at your consultation. Our rooms can also arrange for an interpreter to be present but we need to know in advance as they need to be booked ahead.
    South East Colorectal collects the above information on you for the primary purpose of providing quality health care, including an accurate patient record. This information is used for administrative purposes, disclosure to others involved in your health care, for referral on to other doctors and specialists, for hospital admissions, or for medical tests. Our practice has a privacy policy on the handling of patient information and South East Colorectal upholds the highest standards of patient confidentiality.

    Our practice is also a teaching facility, therefore students may sometimes be in attendance during your consultation. Please advise reception if you do not wish to have a student present during your consultation.

    I understand that there will be costs involved in my consultation and that payment of my account is due on the day of my consultation.  I confirm that I have read and understood the above and by clicking SUBMIT I give my consent to South East Colorectal to use my information as outlined above.
Submit
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