Privacy Consent Form

The Brisbane Eye Clinic respects and upholds your rights to privacy protection under the National Privacy Principles contained in the Privacy Act 1998. The National Privacy Principles apply to us from their introduction on 21 December 2001. Under these guidelines, the Brisbane Eye Clinic requires your permission to collect personal information about you and to use this information in the management of your medical care. This practice has a Privacy and Information Handling Policy and copies are available for your perusal at any time.

Please carefully read the following information about privacy issues then sign this form where indicated overleaf. This document will be retained with your patient records.

The Brisbane Eye Clinic may hold the following information about you:

  • Name, address, telephone numbers, email address
  • Date of birth
  • Occupation
  • Health information (including details of your medical history, family medical history, notes made during consultations, results of investigations, reports received from other health providers)
  • General practitioner, referring doctor, other specialists involved in your care
  • Returned Service Organisation
  • Pensioner or Health Care Card details
  • Medicare number
  • Transaction details associated with services provided to you by providers at Brisbane Eye Clinic
  • Additional information provided to us by you
  • Information provided to use through patient/referrer surveys

This information is collected in order to provide you with the optimum medical care.

During the management of your medical condition it may be necessary for the Brisbane Eye Clinic to use this information in the following ways:

  • By providing written or verbal reports to other Medical Practitioners or allied health professionals involved in your care to help keep them informed about your progress
  • Referrals to other Medical Practitioners, pathology services, radiology services or allied health professionals or health organizations for services to assist in your medical care
  • In the event that you are somehow incapacitated and therefore unable to provide 'informed consent' in relation to emergency medical care, the person that you nominate as your next of kin on the 'Patient Information Sheet' will be contacted
  • The administration of the medical practice
  • To process claims for payment to private health funds and Medicare in accordance with Health Insurance Commission and health fund requirements
  • To disclose to others for medical defense purposes if necessary


I have read this form and understand why collecting information about me is necessary. I am also aware that this practice has a Privacy Policy on handling patient information.

I understand that I am not obliged to provide any information requested of me. I also understand that failure to provide this medical practice with all the information it needs may restrict the practice's ability to provide quality of health care and treatment that I require.

I am aware that I have the right to access the information collected about me except in circumstances where my access might legitimately be withheld. I understand that I will be given an explanation in these circumstances.

I understand that should my information be required to use for any other purposes other than that set out above, my consent will be obtained.

I consent to the handling of my information by this practice for the purposes set out above, subject to any limitation, access or disclosure about which I notify this practice in writing now or at any time in the future.

In addition, I authorise the Brisbane Eye Clinic to contact me via telephone, email, or SMS for appointment changes and understand that these forms of communication may also be used for appointment reminders in the future.

I acknowledge that I have read and understand the content within this form.

Should you wish to nominate any restrictions with respect to your personal information, please provide details below:

Given Name
Family Name