• (08) 6153 4535
  • Suite 1, Level 1, Medical Centre, SJOG Hospital

  • Patient's details and Consent form
  • PARENT/GUARDIAN
  • Child Protection
  • PATIENT CONSENT FORM
  • Practice Policies

CHILD’S DETAILS

Title

Gender

DOB

Age

First Name

Middle Name

Surname

Country of Birth

Address

State

Postcode

Medicare number

Ref

Exp

Private Health Fund

Member number

Mother’s details

Name

DOB

Address

Occupation

Number

Email

Country of Birth

Medicare #

Ref #

Exp

Father's details

Name

DOB

Address

Occupation

Phone Number

Email

Country Of Birth

Medicare #

Ref #

Exp

Is the child under care of CEO of the Department of Child Protection?

If yes, the DCP authorising officer name

DCP office

Known allergies

PATIENT CONSENT FORM

I AM THE PARENT / GUARDIAN OF:

D.O.B

DO YOU GIVE CONSENT FOR PERTH CHILD DEVELOPMENT CENTRE TO UNDERTAKE ASSESSMENTS, MANAGEMENT AND INTERVENTION RECOMMENDATIONS?

ARE THERE FAMILY OR CHILDREN’S COURT ORDERS IN PLACE FOR THIS CHILD?

DO YOU CONSENT TO PERTH CHILD DEVELOPMENT CENTRE TO OBTAIN AND EXCHANGE REPORTS AND RELEVANT INFORMATION WITH OTHER AGENCIES AND INDIVIDUALS, IF REQUIRED? (ELECTRONIC, PICTORIAL, VERBAL AND WRITTEN)

REFERRING GP

Attach GP's referral letter

Max. size: 32.0 MB

SCHOOL (PRINCIPAL, TEACHING STAFF, SCHOOL PSYCHOLOGIST & SCHOOL NURSE

DAY CARE

CHILD HEALTH NURSE

OTHER PROFESSIONALS/AGENCIES

OTHER INDIVIDUALS INCLUDING THOSE WHO MAY BRING THIS CHILD TO APPOINTMENTS)

AGREE

Practice Policies

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY & SIGN BELOW. PRACTICE POLICY BOTH THE PAEDIATRIC AND ALLIED HEALTH SERVICES PROVIDED AT PCDC REQUIRE YOUR CONSENT TO COLLECT PERSONAL INFORMATION ABOUT YOU. WE COLLECT INFORMATION FROM YOU IS TO ENABLE US TO PROVIDE YOU WITH A QUALITY SERVICE. THE INFORMATION WE COLLECT ALLOWS US TO PROPERLY ASSESS YOUR SITUATION, PROVIDE APPROPRIATE INFORMATION & ADVICE, AND ASSIST YOU IN ACHIEVING YOUR GOALS. WE ALSO USE THIS INFORMATION FOR ADMINISTRATIVE PURPOSES IN RUNNING OUR BUSINESS AND FOR CORRESPONDENCE WITH OTHERS INVOLVED IN YOUR FAMILY’S HEALTHCARE INCLUDING DOCTORS, SPECIALISTS, AND OTHER HEALTH PROFESSIONALS. LATE CANCELLATIONS/NO SHOW POLICY IN ORDER TO PROVIDE OUR PATIENTS WITH THE BEST POSSIBLE CARE, BOTH PAEDIATRIC AND ALLIED HEALTH SERVICES AT PCDC OPERATE ON AN APPOINTMENT-BASED SYSTEM. NO-SHOWS, LATE-COMERS AND LATE CANCELLATIONS IMPACT GREATLY ON OUR ABILITY TO PROVIDE A HIGH-QUALITY SERVICE, BY INTERRUPTING THE SMOOTH RUNNING OF THE PRACTICE. CLIENTS THAT REPEATEDLY MISS OR RESCHEDULE APPOINTMENTS WILL REGRETFULLY BE DISCHARGED FROM CARE. PLEASE PROVIDE US WITH AT LEAST 24-HOUR NOTICE(48HR PREFERRED) IF YOU NEED TO RESCHEDULE YOUR APPOINTMENT. WHERE POSSIBLE, WE WILL TRY TO RESCHEDULE YOU TO THE NEXT EARLIEST CONVENIENT APPOINTMENT. IF LESS THAN 24-HOUR NOTICE IS GIVEN FOR A CANCELLATION, A CANCELLATION FEE OF $50.00 WILL BE CHARGED. THIS FEE IS NOT COVERED BY COMPENSABLE BODIES AND MUST BE PAID BY THE PATIENT. THIS FEE ALSO APPLIES FOR NO-SHOWS. IF YOU ARE RUNNING LATE, PLEASE GIVE US AS MUCH NOTICE AS POSSIBLE. WE WILL ATTEMPT TO ACCOMMODATE YOU. IF THERE IS A PATIENT BOOKED IMMEDIATELY AFTER YOU, YOUR APPOINTMENT MAY UNDERSTANDABLY BE CUT SHORT. PAYMENTS ARE DUE IMMEDIATELY ON COMPLETION OF SERVICE. ON COMPLETION OF ONE ADDITIONAL SESSION IF YOU HAVEN’T CLEARED YOUR BALANCE, YOUR APPOINTMENT WILL BE GIVEN AWAY TO ANOTHER CHILD/FAMILY. PRESCRIPTION REQUEST NO

Agree and accept

Accept

Name

Date

Once you have completed and submitted this online form, please send your GP's referral to the pediatrician to perthcdc.info@gmail.com as soon as possible. This will help us prevent any delays in processing your intake form. Thank you for your time.

Once you have completed and submitted this online form, please send your GP’s referral to the pediatrician to perthcdc.info@gmail.com as soon as possible. This will help us prevent any delays in processing your intake form. Thank you for your time.