Client Information and Consent Form

1

Your details

Fields marked with a red star are the ones we can't book you in without.

Title

First name Please enter your first name

Last name Please enter your last name

Preferred name What you'd like us to call you, if it's different

Date of birth

Day

Month

Year

Please enter a valid date of birth

Street address Please enter your street address

Town or suburb Please enter your town or suburb

Postcode Please enter a 4-digit postcode

Mobile phone Please enter a contact number

Home phone

What kind of mobile phone do you have? Some hearing aids connect straight to your phone, so this helps us advise you properly

Email address Used for appointment reminders and your copy of this form Please check the email address — it doesn't look quite right

Your doctor's name and medical practice So we can send your results to them

Pensioner concession card number If you have one

DVA number If you're a veteran

Private health fund If applicable

2

Medical history

Please answer all of these. If you're not sure about one, choose the closest answer and we'll go through it with you at your appointment.

3

Information and consent

Please read this, then sign at the bottom.

I consent that if medical advice is needed, I should see my medical practitioner. I understand that all records are confidential and governed by the Privacy Act.

Release of medical information

As a result of the Federal Privacy Act, AIM Hearing Pty Ltd requires your consent to collect personal information and medical history from professionals associated with your health care.

The main purpose for collecting and using your information is:

To provide you with the best possible health care.
To ensure quality and continuity of care and provide the appropriate testing.
To use in correspondence to other healthcare providers and administrators as required (regarding your personal and health details), including the release of test results to your treating doctor, whether that is a GP, ENT specialist or other.
To use for the administrative purposes of running the practice, including for billing purposes and collection of fees, and compliance with Medicare, the Health Insurance Commission, Workers Compensation, the Department of Veterans' Affairs (DVA), the Office of Hearing Services (OHS), hearing aid manufacturers and Cochlear Ltd as appropriate.

Please note: your medical information may need to be shared with other allied health providers and administrators from time to time for medico-legal purposes.

Hearing Services Online Project

The Office of Hearing Services (OHS) operates an online portal system to support the administration of the voucher component of the Australian Government Hearing Services Program. The portal aims to reduce red tape and improve access to the OHS program by providing quicker eligibility and application processing for clients, and reducing the waiting time and number of paper forms needed to access hearing services.

Clients can use the portal to:

Confirm their eligibility for the Program.
Submit an application for a Hearing Services Voucher.
View the Hearing Services provider directory in a searchable map.

Hearing Services Program client consent

By signing this form, you are acknowledging and giving consent for AIM Hearing Pty Ltd to use the portal to:

Apply for a Hearing Services voucher.
Record your client consent.
Process a return voucher.
View and manage client details.
Submit a request to transfer you from another service provider.
Manage all your Hearing Service requirements.

Private client consent

By signing this form, you are giving consent for AIM Hearing to become your hearing services provider, and permission to request your file from your previous provider.

Collection, storage and procedures

I consent to AIM Hearing Pty Ltd collecting and storing my personal and medical information, and sharing my personal information with related health professionals which in the opinion of AIM Hearing are necessary for my health and wellbeing.

I understand that cerumen (ear wax) removal and/or impression taking involve minor risks such as small abrasions or minor bleeding. In the event of uncommon abrasion or trauma, I will be referred to my GP or ENT for treatment. I have notified the clinician now present of any medications or conditions that could impact this procedure.

Please note: ear wax removal is not covered by the Hearing Services Program and attracts a charge to the client.

Private services acknowledgement I understand that some services, including ear wax removal, are not covered by the Hearing Services Program and will attract a fee. Please tick to acknowledge the private services fee

I have read and consent to the above This covers collection and storage of my information, sharing it with my health professionals, use of the OHS portal, and the ear wax removal and impression procedures described. Please tick to give your consent — we can't proceed without it

Your signature

Type your full name below. Under the Electronic Transactions Act, this counts as your signature when you also tick the box confirming you intend it to.

Type your full name Please type your full name to sign

Signed on —

I confirm this is my electronic signature I am the person named above, and I intend this typed name to have the same effect as my handwritten signature. Please confirm your electronic signature

Email me a copy of this form for my records Recommended. Untick if you'd rather not receive one — reception can print you a copy at the desk instead.

Send my copy to Please enter an email address, or untick the box above

Client Information & Consent Form