Patient Information

Thank you for attending this practice. We look forward to being of assistance to you.

A current referral to see the specialist is a requirement to enable you to claim your entitled Medicare rebate.

A referral from your GP will last for 12 months and from another Specialist will last 3 months.

about us

WA Paediatric Surgery & Urology care for babies and children

Patient Information Sheet

We have the Patient information Sheet available as a printable PDf as well as an online form which you both find below.

For the PDF version, please download, complete and resend this Patient Information sheet, and Privacy Policy and Consent via the emails on our website. Don't forget to bring along your referral letter on your first visit.

All fields are required in the form.

Download Patient Information Sheet

Online form

All fields are required in the form.

Step 1 of 4

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Select doctor*
Please enter the childs details
Childs name*
First name Surname
Postal Address*
Street address + number Suburb Postcode
Gender*
- Male
- Female
- Intersex
Date of birth*

Day
Month
Year

Please enter parent / guardian details
Who is accompanying the child?*
- Mother
- Father
- Guardian
Mother's full name*
Prefix First Last
Mobile*
Father's full name*
Prefix First Last
Mobile*
Parent / Guardian's full name*
Prefix First Last
Mobile*
Email address*
Medicare number*
Expiry date*
Reference number*

(Number on left of child's name on card))

Hospital cover?*
- Yes
- No
DO NOT COMPLETE IF ANCILLARY COVER ONLY
Health Fund Name*
Health Fund Membership Number*
REF
Less / more 12 months*
- Less
- More
Referring Doctor's Name*

REFERRALS MUST BE CURRENT AT ALL TIMES - PARENT RESPONSIBILITY
Usual GP's Name*
Usual GP Address*
Street and number Suburb Postcode
Medicare Online Claiming?*
- Yes
- No
TO ENABLE MEDICARE ONLINE CLAIMING - PARENT MEDICARE DETAILS REQUIRED
Account holder full name on Medicare Card*
Account Holder Date of Birth*

Day
Month
Year
Account Holder's Medicare Number*
REF*

Consent and submit form
Consent*
I agree to patient/ parental consent to collect and disclose information
The Privacy Act 1988 requires medical practitioners to obtain consent from their patients to collect, use and disclose that patient’s personal information.

Collection
We will collec tinformation that is necessary to provide proper advice and treatment for you/your child. Suchnecessary information may include: full medical history, family medical history, ethnicity, contact details, medicare/private health fund details, genetic information and billing/account details. This information will normally be collected directly from you and/or your child. There may be occasions when we will need to obtain information from other sources, for example: other medical practitioners such as previous GP’s and specialists, other healthcare providers such as physiotherapists, occupational therapists, psychologists, pharmacists, school, nurses or hospitals. Dr Barker/Dr Samnakay and our practice staf may participate in the collection of this information. In emergency situations we may need to collect personal information from relatives or other sources where we are unable to obtain your prior expressed consent. We agree to advise our vaccination status.

Use and Disclosure
With your signed consent, the practice staf will use and disclose your/your child’s information for purposes such as: billing, referral to another medical practitioner/health care provider, sending of specimens, referral to a hospital for treatment, the management of our practice, quality assurance, practice accreditation and complaint handling. Your consent also enables us to meet our obligations to ourmedical defence organisations or insurers, to prevent or lessen a serious threat to an individual’s life, health or safety where legally required to do so, such as producing records to court, mandatory reporting of child abuse or notification of diagnosis of certain communicable diseases.

Access
You are entitled to access your own/your child’s health records at any time convenient to both yourself and the practice.

Access can be denied when:to provide access would create a serious threat to life or health, there is a legal impediment to access, the access would unreasonably impact on the privacy of another, your requestis frivolous, the information relates to anticipated or actual legal proceedings and you would not be entitled to access the information in those proceedings and in the interests of national security.

We ask that, where possible, your request be in writing. We may impose a charge for photocopying or for staf time involved in processing your request. Where you dispute the accuracy of the information we have recorded you are entitled to correct that information. It is our practice policy that we will take all steps to record all of your corrections, and place them with your file but will not erase the original record.

Consent
I have read the above information and I provide my consent for (please circle) Dr Barker/Dr Samnakay and his staf to collect, use and disclose my/my child’s personal information as outlined above. This consent is active for all correspondence whether by mail, phone or in person.
I understand that I am entitled to access my/my child’s records except where access would be denied as outlined above. I understand that I may withdraw my consent as to use and disclosure of my/my child’s personal information (except when legal obligations must be met).
Patient name*
Signed*
Parent / Guardian Full name*
Relationship to patient*
IF YOUR CHILD HAS HAD A SCAN OR BLOOD TEST/S PLEASE ENSURE WE GET A COPY PRIOR TO APPNT. REFERRALS MUST BE CURRENT AT ALL TIMES - PARENT RESPONSiBILITY TO CHECK WITH ROOMS
Spam prevention*

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Coming in for operations

Please strictly observe pre-operative fasting times as prescribed by the Consultant Anaesthetist. Fasting is essential for a safe anaesthetic for your child. If children are not correctly fasted, procedures will need to be delayed or cancelled and rescheduled.

Please come in to the hospital at the time advised by the Consultant Anaesthetist. Operating lists are usually in the order of age, youngest children first, or in order of medical need and priority. Times for surgery are estimates. In cases where lists get delayed, your understanding and co-operation are greatly appreciated.

After-surgery care information

Bladder Diary

Please feel free to print and complete the bladder diary provided if the doctor has requested one. Kindly email the diary prior to your follow-up appointment.

Bladder diary

Contact our paediatric surgeons and urologists

Should you have any queries about any of the surgical services that we offer, or about your child’s care, please get in touch with our friendly practice managers.

fields marked with * are required
What is your full name?*
First name Surname
What is your child's full name?*
First name Surname
Child's date of birth*

Day
Month
Year
Your email address*
Your phone
Select your surgeon*
How can we help you?*
Please attach Files - eg Referral, Completed and signed Patient Information and Privacy Policy Sheet
Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 1 MB, Max. files: 5.
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