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Dr. Hugh Derham – Step 1

  • (Please fill in if it’s different than your Residential Address)

  • HCC/Pension Number: Expiry: DVA Number:  
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  • Private Health Fund Member Number  
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  • Additional Patient Information

    (if patient is under age of 18)
  • Account Holder: Medicare Number: Individual Number on Medicare:  
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  • Health Quest Medical Clinic TERMS OF AGREEMENT

  • Patient Consent to Collect and Disclose Information.

    The Privacy Act 1988 requires medical practitioners to obtain consent from you, the patient, to collect, use

    and disclose your personal information. This information is needed to properly treat and advise you, and

    may be collected by the medical practitioner or our practice staff.

    Information collected, used and disclosed may include full medical history, family medical history, genetic

    and ethnicity details.

    Normally we would collect the information directly from you but there may be occasions when we will

    need to obtain the information from others, such as:

    1. Other general medical practitioners and specialists.

    2. Other health professionals such as physiotherapists, psychologists, psychiatrists, pharmacists,

    nurses, dentists, etc.

    3. Hospital and Day Surgery facilities.

    In an emergency we may need to obtain personal information from relatives or other sources if we are

    unable to obtain your express prior consent.

    Use and Disclosure

    The practice will only use and disclose your personal and health information for the following reasons:

    1. Account keeping and billing purposes.

    2. Referral to a medical specialist or another health care provider.

    2A. Provision of a prescription in digital form to a pharmacy to which you have taken a


    3. Referral to a hospital for treatment and advice.

    4. Advice on treatment options.

    5. Day to day management of this practice, including disclosure to practice health professionals,

    administrative staff, and information technology staff and contractors for the purposes of

    maintaining and improving the practice’s systems.

    6. To meet our obligations of notification to our insurers and medical defence organisation.

    7. To prevent or lessen a serious threat to an individual's life, health or safety.

    8. Where legally required to do so, such as providing records to a court, mandatory reporting of

    child abuse or the notification of diagnosis of certain communicable diseases.

    Access to your records

    You are entitled to access your own health records at any time convenient to both yourself and the


    Consent to be included in the Practice reminder system

    In order to provide continuity of care, and in the interests of preventative medical management the

    practice maintains a reminder system. Your consent is needed to be a participant in the recall system,

    and you have the right to refuse if you wish.

    Disclosure of Financial Interest 

    The practitioner you see has or may have a direct or indirect financial interest in a pharmaceutical

    manufacturer or wholesaler of medications which the practitioner may prescribe or in a provider of

    pathology or imaging services to which the practitioner may refer you.  The practitioner will prescribe or

    refer on the basis of his or her professional judgement but you are not obliged to follow those

    recommendations in sourcing the medications or services.  If you wish to consider alternative providers,

    please discuss this with your practitioner so he or she can explain the basis of the professional judgement


    Please read the reverse side of this page and sign the areas appropriate for you.