Personal Details Medicare Health Insurance Details Referral Details Emergency Contact Details Hospital Admission Workers' Compensation Authority For Release of Information I give permission for you to forward confidential information regarding my injury, the treatment I have received and guidelines for return to work to my employer, insurance company and rehabilitation provider.
Workers Compensation Accounts I understand that should my claim be declined by my insurer, I will be responsible for paying for any unpaid accounts.
Please Note: If this is a new injury and you do not know the above details, please check with your employer and telephone your surgeon’s rooms with this information as soon as possible. Failure to pass on this information or rejection of your claim by the insurance company will result in you being personally liable for any invoices raised in the course of your treatment.
Video / Photo Consent Mr Jeff Ecker regularly and routinely takes photographs and video of patients on their initial presentation, during their treatment and surgery, at the post operative management and the outcome after treatment. The main purpose for these images is for open communication and research to continually strive to improve treatment methods and contribute to the overall knowledge of the medical community. For you, it means that your management will be carried out in an open manner. Not all patients will have videos and images taken. This depends on the facilities available at the time of treatment.
In order to do this, Mr Ecker requires your consent. It is important that you are aware that you can decline to have imaging taken of you during your treatment.
It is important for Mr Ecker to know that you are aware of the following:
Your treatment will not be prejudiced if you do not give consent. If your imaging is used, it will be in a de-identified manner so that nobody will recognise who you are. If you are a Workers’ Compensation case, your images can be shared with the referring caregivers, on site occupational health, the insurance company and your employer. Your images may be used for teaching purposes to teach young doctors and post graduate surgical trainees. Your images may be used in international presentations. Mr Ecker regularly travels overseas and speaks internationally. Your images may be included in these talks. Again, if this is the case, they will be de-identified and no one will be able to link you to the images. Your images and your clinical material may be used for research purposes. The objective of research is to continue to improve the management of conditions of the upper extremity. Baseline data is continually required to know whether or not new treatments are better than the old treatments and to identify problems with current treatments that are not recognised. These images may be viewed in your follow up consultation and may be graphic and confronting. Please advise staff if you do not wish to view your images. Mr Ecker would appreciate if you would let him use your information in this manner, however again refusing to have images made will not prejudice your treatment .
You may wish to consent to certain uses of material and exclude others. If you have any comments, Mr Ecker would appreciate your feedback.
Agreement Mr Jeff Ecker will record photographs, video or digital images of me during my medical treatment, including but not limited to my initial consultation and assessment, surgery, post-operative procedures, and any follow up consultations, performed by Mr Jeff Ecker which will be:
Please tick any appropriate statements to which you consent to the photographs, video or digital images being used
Accessed by all parties involved in my medical treatment, including but not limited to referring medical practitioners, medical interns, medical students, nurses, insurance companies, general practitioners, physiotherapists, and occupational therapists;
Used for teaching purposes, including but not limited to seminars, lectures, conferences, and workshops in which all photographs, videos or digital images will be de-identified to protect my confidentiality; and
Used on the Hand and Upper Limb Centre website, in which all photographs, videos or digital images will be de-identified to protect my confidentiality.
Patient Medical History Are you left or right hand dominant?
Current Medications
Are you taking any anticoagulants (blood thinners, i.e. Warfarin, Xarelto, Plavix, Eliquis, aspirin, fish oil)? Medical Conditions Do you have, or have you ever experienced, any of the following medical conditions?
Allergies Please tick the box of any allergies you may have.
Anaesthetic Risks Please tick the box of any anaesthetic risks you may have.
How did you hear about us? Review your details Personal
Name
{{ patient_title }} {{ patient_first_name }} {{ patient_last_name }}
Medicare Health Insurance Referral Details Emergency Contact Hospital Admission Patient Medical History Submitting the form By submitting this form you confirm your consent for us to collect this information from you for the primary purpose of providing quality health care and confirms your acceptance of correspondence via your email address and SMS. The information will also be used for administrative, billing and debt collection purposes, and for referrals and requests regarding your healthcare.
I consent to the information contained in this form being shared with the HAND AND UPPER LIMB CENTRE for relevant treatment and/or research purposes.
Thanks, we have recieved your message and will get back to you shortly.
It seems something isn't quite right. Please check the fields marked and try again.
