Clinical Neurology Services
About
Dr Darshan Ghia
Dr Twinkle Ghia
Dr Najm Khan
Services
Neurological Consultations
Neurophysiology Tests
Paediatric NCS / EMG Test
EEG Test
Ambulatory EEG Testing
Paediatric Neurology
Conditions
Migraine and Headache
Epilepsy
Seizure
Multiple Sclerosis
Stroke
Patient Info
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New EEG Patient Form
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Patient's Name
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Next of Kin's Name
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Do you authorise your next of kin access to your medical records?
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Do you authorise your next of kin to schedule or cancel appointments?
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Do you authorise your next of kin to access financial information regarding your account?
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Do you consent for your consultation information to be uploaded to your MyHealth Record?
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Are you Aboriginal or Torres Strait Islander?
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Medicare Number
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Name of Referring General Practitioner
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Consent
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I consent to the terms below
I provide consent for Dr Darshan Ghia / Dr Twinkle Ghia to collect, use and disclose my personal information as described by the principles of the Privacy Act 1988 (details are available from reception). I understand that information about me (test results) may form part of professional educational, audit, or research activities. This information is securely stored within our practice in accordance with our privacy policy. Identifiable information about me, however, will not be disclosed publicly with-out further consent.
I understand unpaid Workers Compensation or MVIT claims will be my responsibility to pay. I also acknowledge that unpaid accounts requiring the services of a debt collector will incur an additional charge. As a current doctor’s or optometrist’s referral is required for my full Medicare re-imbursement, I understand that it is my responsibility to keep my referral up to date.
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