Patient Agreement

Patient Name:

Day of Birth *

Month of Birth *

Year of Birth *

I ,
confirm that I have read the patient information and practice policy handout or website information

I agree to take responsibility for my own health and be an active partner in my own healthcare

I agree to attend all appointments, treatment schedules and consultations as requested by my physician

I understand and agree to the policies of this practice, specifically:

	I will bring my health card and a list of my medication to every visit and I understand that I may not be seen without a valid health card.
	I understand that I will be asked to complete online patient forms before every visit.
	I am aware that there are fees associated with some uninsured services and I am responsible for paying these (e.g. sick note, disability forms, insurance forms and medical reports)
	I understand that it is NEVER acceptable to verbally or physically abuse any clinic staff and that such behaviour will lead to immediate termination of the physician-patient relationship.
	I understand and agree to the principles of this practice. If I am unable to follow these principles, I am aware I may be discharged from the practice.

Signed:

Date:

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