New Patient Form

Not all of the below sections will be applicable to your situation. Please fill in all relevant information

In consenting to consultation and mutually agreed treatment, I understand that:
- A written record of history and examination relative to my condition will be recorded in the casenotes/computer records of Dr. Nimon.
- It may be necessary to share information with other Health Providers, eg (General Practitioner, Orthopaedic Colleague, Pathology, Radiology, Physio, Podiatry Services), for further investigation and treatment of my condition.
- There may be a legal request/s that cannot be refused, outside of my personal privacy rights.
- I consent to requested reports being sent to Workcover or insurer (if applicable).
- I undertake to notify Dr. Nimon of any specific information I do not wish forwarded to the above alternative Health Providers.
- I give consent for material (photos or x-rays) to be used for teaching/research or website purposes.
- I accept responsibility for the full financial settlement of my account to be paid on the day of consultation, unless I am covered by Workcover with an accepted claim (unless I am unable to provide accepted Workcover claim details or if the indicated claim has been suspended or closed). I accept that default can result in my personal details being forwarded to a Debt Collection Agency, for pursuit of outstanding amounts, which will incur further fees to be paid by myself.
A copy of Dr. Nimon's Privacy Policy for protection of patient confidentiality is available for perusal, on request, from the Practice Manager/ Privacy Officer. Please direct any enquiries to the Practice Manager/ Privacy Officer

I give my authorisation for Dr Nimon to provide me with Telehealth Consultations which will then be billed through Medicare.