New patient form – Central West Urology

Contact details

First Name

Middle Name

Last Name

Date of birth

Patient Gender

Mobile phone

Home phone

Email

Address

Address Line 1

Address Line 2

Suburb

State

Postcode

Emergency Contact

First Name

Last Name

Phone/Mobile

Relationship

General information

I would prefer to receive communications regarding appointments from Central West Urology by

Email

Post

Occupation

Retired?

Yes

No

Indigenous status

Aboriginal

Torres Strait Islander

Neither

Who is your GP?

Doctor’s name

Name of GP practice

Medicare & Health Insurance

Medicare number

Ref

Expiry date

Health fund

DVA

Concession

Health fund

Fund number

Ref

Expiry date

Name on card

DVA number

Card type

Expiry date

Name on card

Health Care Number

Expiry date

Pensioner Concession No

Expiry date

This clinic uses AI medical scribes

Central West Urology uses Artificial Intelligence (AI) medical scribe tools to help health practitioners record accurate clinical notes during a patient consultation.

AI medical scribes listen in the background, capturing only the relevant details relating to clinical documentation requirements. These details are then transcribed into text to be sent to your health practitioner’s Electronic Medical Record system.

Here’s what you need to know:

Transcription is performed exclusively within Australia
Audio file is immediately destroyed post-transcription
Transcription is redacted of sensitive, personal identifying information received
The transcript is encrypted – it is not stored in its original form
Only your health practitioner can access this content
At the discretion of the practitioner, data may be stored temporarily.
If you have any questions, please ask your health practitioner

By providing your signature below, you are consenting to your health practitioner using an AI medical scribe to transcribe clinical notes

Or

I do NOT consent to the use of an AI medical scribe by my health practitioner during my consultation

Would you prefer to have a telehealth (video call) or in-person appointment?

In-person

Telehealth

Telehealth consultation informed consent

Telehealth is the use of the internet or telephone to provide remote health care for patients. Specifically, your specialist will be communicating with you remotely using a web-based audio-visual software, or over the telephone where deemed appropriate. This telehealth appointment may be for diagnosis, continuity of care, or medical consultation deemed necessary by your specialist or you.

The benefits of having a telehelath consultation can be:

Reducing the waiting time to see a specialist
Avoiding the need to travel to the specialist

The risks of having a telehealth consultation can be:

A telehealth consultation will not be exactly the same and may not be as complete as an in-person consultation
There could be some technical problems that affect the telehealth consultation
Central West Urology uses systems that meet recommended standards to protect the privacy and secuiry of the telehealth appointments. However, the service cannot guarantee total protection against hacking or tapping into the video visit by outsiders. The risk is small, but it does exist.

If remote consultation does not achieve everything that is needed, then you will be given a choice about what to do next. This could include a follow up in-person visit, or a second telehealth appointment.

You can change your mind and stop the telehealth appointment at any time, including in the middle of a video visit. This will not make any difference to your right to ask for and receive health care.

By providing your signature below, you are consenting to a telehealth appointment

Sign Here