Anglo Gold Ashanti - New Patient Registration Form

Patient Name

Contact Information

Note: At least one contact number is required. At least two contact numbers, with an Email address is recommended.

Next of Kin
General Practitioner
Medicare Details
Note: Please enter the last day of the month specified on your Medicare expiry date (I.e. If it expires in October 2017, you would enter 31/10/2017.
Private Health Insurance
DVA Card Holder
Pension of Health Care Card Holder
Work Cover
Additional Information/Consent (Mandatory)

Access: You are entitled to access your own health records (except where access can be denied) at any time convenient to both yourself and the practice. A fee may apply for records you request. For more information on this matter, please ask our staff for assistance.

Consent: I provide my consent for Dr J C Philpott to collect, use and disclose my personal information as outlined in the Privacy Act, made available for reading at my request.  Sleep WA's privacy policy can be found on our website, at the bottom of the home page under the "about us" heading.  If required, I agree to release my relevant information to your preferred therapy provider.

By signing this consent form, I agree that I am giving permission for Sleep WA to provide my personal information as outlined in the Privacy Act to AngloGold Ashanti Australia Ltd and my employer.

I understand that I may withdraw my consent as to use and disclosure of my personal information (except when legal obligations must be met.

Payment of your account is required on the day of your appointment.  The Medicare benefit (if applicable) can be processed on your behalf.

An administrative fee of 20% of the amount owed will apply to all accounts outstanding 30 days or more

Consent for Retention of personal information (optional)

At Sleep WA we are committed to providing excellent health care for sleep related disorders. For this reason we believe it is essential to continually assess the effectiveness of our various therapies and aim to improve them where possible. This is achieved using research projects.
You are invited to give consent for your personal information to be collected for the purpose of clinical audit or research. This information may include clinical details taken from your medical records, sleep questionnaire or test results.

Your personal information will be stored on the Sleep WA database which is password protected and accessible only by Sleep WA employees. Any information taken from the clinical database and used for the purpose of research will have all identifying information removed. Your information will not be shared with any other parties. The information collected will be used only for research projects related to sleep disorders and their treatment. This research may be published in medical journals or presented at medical conferences. Any research projects will be presented to the Hollywood Private Hospital Research Ethics Committee for approval prior to publishing or presenting.

You may be asked to complete additional questionnaires regarding your therapy. Most of these will be given to you at scheduled appointments but we may occasionally send requests in the mail. You are not obliged to respond to these requests. These questionnaires will be added to your clinical records but any details used for research or clinical audit will have all identifying information removed.

Consent is completely voluntary and can be withdrawn at any time. Withdrawal of your consent will result in your information no longer being used for research. If you would like to discuss any of the above, please contact the Practice at

Declaration of the participant

I have read and understand the above information. I have been given the opportunity to ask questions and I am satisfied with answers I have received. I freely agree to the retention of my personal information for the purpose of research and I am aware that I can withdraw this consent at any time.