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A/Prof Stefan Kane
Practice
Screening for Genetic Conditions
Laboratory Tests
Ultrasound Tests
Appointments & Care
Fees
Online Registration
Common Pregnancy Concerns
Links
Contact Us
A/Prof Stefan Kane
Practice
Screening for Genetic Conditions
Laboratory Tests
Ultrasound Tests
Appointments & Care
Fees
Online Registration
Common Pregnancy Concerns
Links
Contact Us
Online Registration
To register for your appointment, please complete the form below.
Booking Details
Patient Type
Patient Type*
New
Existing
Type of Care
Type of Care*
Antenatal Care
Pre-pregnancy Counselling
Estimated Due Date
Due Date
Have you booked an appointment?
Have you booked an appointment?*
Yes
No
Personal Details
Title
First Name
Last Name
Preferred Name
Date of Birth
Date of Birth
Occupation
Contact Details
Street Address
Suburb
State
State*
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
Telephone Home
Telephone Work
Mobile
Email
Preferred method of contact*
Preferred method of contact*
Phone
Email
Text
Appointment reminders via SMS*
Receive appointment reminders via SMS?*
Yes
No
Partner Details
Partner Name
Partner Date of Birth
Partner Date of Birth
Partner Occupation
Partner Mobile
Health Care Provider Details
GP Details
Practice Name
Doctor Name
Telephone
Fax
Email
Do you have other Specialist/Health Care Practitioners involved in your care (IVF Doctor, Cardiologist, etc.) ? If so, please provide details.
Other Care
Insurance Billing Details
Medicare Number
Medicare Reference
Medicare Expiry Date
Medicare Expiry Date
Private Health Insurance
Do you have Private Health Insurance?
YES I have Private Health Insurance
NO Private Health Insurance
Fund Name
Membership Number
Pregnancy Cover
Do you have pregnancy cover?
YES I have pregnancy cover
NO pregnancy cover
Self Funded
Are you self-funded?
YES I am self-funded
NO I am not self-funded
Financially Responsibility
Who will be the financially responsible party?
Who will be the financially responsible party?
Myself
Other
Account holder - Name
Account Holder Date of Birth
Account holder - Address
Account holder - Phone
Account holder - Email
Account holder - Relationship to Patient
How did you hear about us?
Referral method
Privacy Statement & Consent
In order to provide you with the highest standard of obstetric care, I will ask for personal information from you. This information covers basic details such as your name, address and telephone number but it is also necessary to know about your general health and past medical or surgical events. Without this general health picture, I am unable to plan your care properly. Naturally, some of this information is of a personal nature and some of it might be regarded as ‘sensitive’ and not the sort of information that you would wish to be necessarily disclosed to others. We value the need to safeguard this information, and in accordance with the principles laid down in privacy legislation and the guidelines issued by the Australian Medical Association, we would like to assure you that:
This information will only be used to individualise and optimise your care.
It may sometimes be necessary to disclose some information to other doctors and health professionals involved in your care (midwives or physiotherapists most commonly). They are also bound by the same privacy obligations.
It is usual practice to communicate with your referring doctor and other specialists involved in your care at the beginning and end of your pregnancy and after pre-pregnancy consultations, as this helps to ensure continuity of care. Please advise us if you do not wish for this to occur.
Your health information will not be disclosed to anyone not associated with your treatment without your express consent.
You may seek access to the information held about you and I will provide this access without undue delay. This access might be by inspection of your medical records at the time of appointment or by special access or copying of information at other times.
There will be no charge made for requesting this information but there may be fees levied to cover the costs associated with the processing of this request or copying of the information.
I will take reasonable steps to ensure at all times that the details we keep about you are accurate, complete and up to date.
I will take reasonable steps to protect this information from misuse or loss and from unauthorized access, modification or disclosure. Our records are stored electronically, on a secure server. All paper-based records that you provide will be scanned and then confidentially shredded.
My staff is trained to respect these principles at all times.
If you have any questions regarding the information I collect from you, please do not hesitate to ask. I am acting in your interests at all times.
Privacy Policy Acceptance
I acknowledge that I have read, understood and agree to the privacy consent.
Informed Financial Consent
I acknowledge that I have read and understood the Statement of Fees including the out-of-pocket expense.
I understand that this is an estimate only and may be subject to variation.
I acknowledge that it is my responsibility to pay all fees and charges.
I understand that other health professionals and services may be involved in my care and this estimate does not include their fees and charges.
Any financial interest that this practice has in any products or services recommended or given has been disclosed.
Financial Acceptance
I acknowledge that I have read, understood and agree to the financial consent.
Submit
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A/Prof Stefan Kane
About A/Prof Stefan Kane
Common Pregnancy Concerns
Links
Make an Enquiry
Practice
Appointments & Fees
Screening for Genetic Conditions
Laboratory Tests
Ultrasound Tests
Practicalities of Care
Online Registration
Location
Contact
A/Prof Stefan Kane
Practice
Screening for Genetic Conditions
Laboratory Tests
Ultrasound Tests
Appointments & Care
Fees
Online Registration
Common Pregnancy Concerns
Links
Contact Us