For PatientsReferral InformationYour AppointmentFormsPayment PolicyPatient InformationTreatment RoomTelehealthUseful LinksAlbany Day HospitalSelf Funded ProceduresHollywood Private HospitalFAQs Patient Forms Patient Details Form Download the PDF Fill out the form online Patient Details Name*(As listed on Medicare Card) Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Name Middle Name Surname Preferred Name Date of Birth* DD slash MM slash YYYY Gender F M Other Residential Address* Street Address Suburb State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Residential Address same as Postal Address This is also my postal addressPostal AddressIf different to above Street Address Suburb State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneMobile*Consent I consent to receive appointment bookings, reminders, & general information via SMSEmail*By providing my email address, I consent to access my patient portal/information in the future MedicareMedicare Number*As shown on card Medicare Ref #*To the left of your name Medicare Card Expiry*Bottom right corner of card Concession CardPlease note: only commonwealth pensions concession cards (Blue) acceptedConcession Card Type Concession Card Number Concession Card Expiry DVA ColourPlease select...WHITEGOLDDVA Number DVA Expiry Private HealthPrivate Health Fund Name Private Health Membership NumberDo you have hospital cover? Yes No Policy held for more than 12 months? Yes No Known excess?GPUsual GP* Practice* Optometrist Usual Pharmacy / Chemist* Is this treatment related to a Worker's Compensation or Motor Vehicle Claim?* Yes No If Yes, please download or complete the online Workers Compensation Form further belowEmergency Contact / Next of KinEmergency Contact Name* Relationship to patient* Phone*Consent I consent to GSSC giving this person my appointment information and requesting other medical info on my behalfPayer / Account HolderIf patient is under 16Relationship Parent Guardian Name Date of Birth DD slash MM slash YYYY PhoneAddress Street Address Suburb State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Medicare NumberAs shown on card Medicare Ref #*To the left of your name Medicare Card Expiry*Bottom right corner of card Signature* PRIVACY POLICY This clinic collects information from you for the primary purpose of providing quality health care. Federal Privacy Law requires your consent to this. We need your personal details and full medical history (which may include photographic records) so that we may properly assess, diagnose, treat and manage your health care needs. This means we will use the information you provide in the following ways: Administrative purposes in running our medical practice, which may include confirmation of your appointment via SMS or emailBilling purposes - including, but not limited to, compliance with Medicare and the Health Insurance Commission requirements.Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports of results returned to us following the referrals.Disclosure to other doctors in the practice, locums and trainees attached to the practice for the purpose of patient care and teaching.Emergency situations whereby medical officers/hospitals may require access to patient notes for treatment purposes. CONSENT I have read the above information and understand the reasons why my information must be collected I understand that I am not obliged to provide any information requested, but that failure to do so might compromise the quality of the health care and treatment given to me.I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld and that an explanation will be given to me in this circumstance. I understand that a charge may be imposed to provide copies of my medical records on request.I understand that if my information is to be used for any purpose other than the above, this clinic will seek my consent prior.I consent to this clinic using my personal information in the ways outlined above.I consent to the use of AI to assist my specialist document my consultation.I also understand that if there is a need for a procedure or treatment, there will be additional fee for these.I understand for security purposes the common area at this clinic is under video surveillance.I understand that my results will be communicated from the treating Doctor via primary SMS/ email contact provided or via my referring doctor.I understand I am responsible to call for my results if I have not had my results confirmed within in reasonable time frame.I understand that consultations are not routinely bulk billed &/or not payable by private health insurance, and consult fees are payable on the day of consultation.Workers Compensation Patients: I understand if I do not provide appropriate insurance information and policy number, I am responsible for payment.I understand most services attract a Medicare rebate, and my invoice will be sent electronically at the completion of my appointment. The rebate is deposited to your nominated bank account (details with Medicare) within 24-48 hours.I understand it is my responsibility to ensure I have a current valid referral, however GSSC will remind me when appointments are made. It is noted referrals from a General Practitioner or Optometrist are valid for a 12 month period, and referrals from Hospital doctors or specialists are only valid for 3 months. Each referral is condition specific.Consent* I have read and agree to the Patient Consent to Collection, Disclosure & Access of Personal Information.* Workers Compensation Details Form Download the PDF Fill out the form online Workers Compensation Patient DetailsPatient name* First Name Last Name Date of Birth* Day Month Year Patient Phone*Employer DetailsCompany Name* Representative Name* Insurance Company DetailsClaim ID* Company Name* Company Manager* Claim Manager* Claim Manager Phone*Claim Manager Email* Injury/Illness DetailsInjury/Illness*Location on Body*Location Where Injury Occurred*Date of Injury* Day Month Year Time of Injury* : Hours Minutes AM PM AM/PM Capsule Endoscopy Patient Form Download the PDF Fill out the form online Capsule Endoscopy Patient Information Patient ID (GSSC)* Date of Birth* Day Month Year Patient Name* First Name Last Name Address* Address Suburb State Postcode Phone*What medications are you currently taking? What medications have you taken in the last month? Have you ever undergone a capsule endoscopy?* No Yes Do you have any allergies?* No Yes If you do have any allergies, please provide details Have you taken NSAID regularly (one month or more)?* No Yes If you have taken NSAID, which one/s and for how long? Have you ever had episodes of total or partial digestive tract obstruction?* No Yes Have you ever had surgical interventions on your digestive tract?* No Yes If you have, what type of surgery? Have you suffered from diabetes mellitus?* No Yes Have you suffered from swallowing disorder or problems?* No Yes Have you suffered from any chronic GI diseases (e.g. Crohns Disease)* No Yes Do you have any implanted medical devices? (e.g. Pacemaker)* No Yes If yes, please provide details Have you taken - 2 x Pico-Salax sachets the night before your procedure, as instructed?* No Yes Have you taken - 2 x Pico-Salax sachets the night before your procedure, as instructed?* No Yes Time of Commencement* : Hours Minutes AM PM AM/PM Time of Completion* : Hours Minutes AM PM AM/PM Signature of Nurse*Signature of Doctor* GSSC Intravitreal Injection Consent Download the PDF Skip to content Open toolbar Accessibility Tools Increase Text Decrease Text High Contrast Negative Contrast Reset