Patient Intake Form

Patient Intake Form Template for Australia

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Key Requirements PROMPT example:

"I need a Patient Intake Form for my new dental practice opening in Sydney in March 2025, with a focus on pediatric patients and the ability to capture detailed dental history and parent/guardian consent."

Document background

The Patient Intake Form is a critical document used across Australian healthcare settings when establishing a new patient relationship or updating existing patient records. It serves multiple purposes: collecting essential patient information, documenting medical history, obtaining necessary consents, and ensuring compliance with Australian privacy and healthcare regulations. The form typically includes sections for personal information, Medicare details, medical history, current medications, emergency contacts, and various consents required under Australian law. It must comply with the Privacy Act 1988 (Cth), relevant state health records legislation, and healthcare identifier requirements. This document is fundamental to establishing the provider-patient relationship and ensuring proper record-keeping in accordance with Australian healthcare standards.

Suggested Sections

1. Patient Personal Information: Basic demographic information including full name, date of birth, address, contact details, and Medicare number

2. Emergency Contact Details: Information for at least two emergency contacts including relationship to patient

3. Primary Healthcare Provider Information: Details of regular GP and any other treating healthcare providers

4. Medical History: Comprehensive medical history including past surgeries, chronic conditions, and allergies

5. Current Medications: List of all current medications, including dosage and frequency

6. Family Medical History: Relevant family medical history for major conditions

7. Privacy Statement: Statement explaining how patient information will be collected, used, and protected

8. Consent for Treatment: General consent for medical treatment and procedures

9. Financial Responsibility: Agreement regarding payment for services and billing procedures

10. Communication Preferences: Patient preferences for appointment reminders and other communications

11. Signature and Declaration: Patient signature confirming accuracy of information and agreement to terms

Optional Sections

1. Insurance Information: Details of private health insurance if applicable

2. Cultural Background: Information about cultural background and specific needs, particularly relevant for Indigenous patients

3. Interpreter Requirements: Section for patients requiring language interpretation services

4. Mental Health History: Detailed mental health history when relevant to treatment

5. Advanced Care Directives: Information about existing advanced care directives or end-of-life wishes

6. Workers Compensation: Additional information for work-related injuries or conditions

7. Research Participation Consent: Optional consent for participation in research or clinical trials

Suggested Schedules

1. Medical History Questionnaire: Detailed questionnaire about specific medical conditions and history

2. Medication List Template: Structured template for listing current medications

3. Privacy Policy: Full privacy policy and information handling procedures

4. Fee Schedule: Current schedule of fees for various services

5. Patient Rights and Responsibilities: Detailed document outlining patient rights and responsibilities

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Medical Services

Allied Health

Mental Health

Dental Services

Hospital Services

Primary Care

Specialist Medical Services

Community Health

Aged Care

Relevant Teams

Reception

Administrative

Clinical

Compliance

Medical Records

Patient Services

Quality Assurance

Risk Management

Information Technology

Legal

Relevant Roles

General Practitioner

Medical Receptionist

Practice Manager

Healthcare Administrator

Nurse

Medical Records Officer

Compliance Officer

Privacy Officer

Allied Health Professional

Specialist Physician

Dental Practitioner

Mental Health Professional

Clinical Director

Quality Assurance Manager

Patient Services Coordinator

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Authors

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