T 07 3193 3381 F 07 3319 6675
E admin@drtheodoratos.com.au
Head Office Suite 3, 19 Lang Parade, Milton QLD 4064


Welcome to the Practice of Dr Oreste Theodoratos


The following questionnaire is completely confidential and will only be accessed by Dr Oreste Theodoratos. You are welcome to complete as much (or as little) of the questionnaire as you feel necessary. 


In order to get the most out of your appointment with Dr Theodoratos, we recommend that you answer each question as accurately as possible. The more information the better!


We kindly request that you complete the Personal Contact Details, Next of Kin and Medicare fields on the following page to the best of your ability. 



Personal Contact Details


Next of Kin

Medicare & Health Fund / Veterans Affairs / Workcover



General Practitioner Details

Other Treating Specialists

Preferred Pharmacy Details


History & Medications


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Please attach any relevant reports, correspondence, investigations etc.

Social History



Fees

New assessments may require up to three (3) visits. These appointments consist of an initial consultation to gain a general understanding of your current situation. A second or third assessment may be required to ensure Dr Theodoratos can obtain a detailed understanding of the reason for referral.

Future follow-up / review appointments are usually 20 minutes, however, if you anticipate requiring an extended appointment please enquire. 

Please note if an alternate consultation is required (e.g. collateral interview) these will be discussed during your appointment.


Duration     Fee             Current
Medicare Rebate
New Patient Consultation
50 minutes

$430.00$231.65
Review Appointment (Standard)
20 minutes

$192.00$76.95
Review Appointment (Extended)
50 minutes

$385.00$163.45

Privacy Policy

Due to the Federal Privacy Act 1988, we require your written consent to collect personal information about you. Please read this information carefully and sign where indicated below.

We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose and treat you. We may need to collect information from previous doctors, health care workers, pathology or x-ray services that you have consulted with, for the primary purpose of providing quality healthcare. This means that we will use the information you provide in the following ways:

  • Best assess your health care needs and provide medical treatment.

  • Administration purposes in running our practice. We may need to contact you using phone numbers provided by you. We may need to send documents, pathology and radiology referrals or letters to the email address provided by you.

  • Billing purposes and debt collection, including compliance with Medicare and Health Insurance Commission requirements.

  • Disclosure to others involved in your care, including treating doctors, specialists and hospital booking staff outside this practice. This may occur through referral to other doctors, surgery at hospitals, for medical tests and in the reports or results returned to us following the referrals.

  • Collection of data for research purposes. This information is used to improve our treatment protocols, which will enable us to improve our quality of care. The data is kept in a secure manner and only staff involved in the research has access to them. You may be contacted at some time in the future for follow up purposes. No information that can be used to identify you will be included in any publication of the research results. You may withdraw from the research at any time.

  • You may be contacted for follow up in the future to ensure the long term results of your procedure.


You have the right to see any health information we hold about you as well as the ability to correct any details that are not accurate.

Consent

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Signature of Patient
Date
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Please upload a copy of your referral, any previous correspondence and/or reports that you would like Dr Theodoratos to receive