By signing this form, I certify that I have read and answered all the questions accurately to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I understand that all tests and measurements are non-refundable. I understand that this practice is NOT a Bulk Billing Practice and I am responsible for full payment for all services rendered on the day of my appointment and that if I am an Inpatient at the Mater Hospital I am responsible for full payment of all services rendered on the day of my appointment. I also understand that if a third party (eg. Rockhampton Hospital, Work cover) is covering the cost of my consultation and they refuse to pay that I will be responsible for the full cost of all services rendered on the day of my appointment. I authorise this practice to release any of my personal/medical information (released via fax, post, email, medical-objects & Oculo) including the diagnosis, and the records of any treatment or examination to any required professionals or institutions including my GP and Optometrist as seen fit by my treating specialist. A copy of REC’s patient privacy policy is available to be viewed at the reception desk on request. I understand that a new referral is required every 12 months (3 months for referrals from specialists). It is my responsibility to ensure that my current referral will be valid for my appointment. If your referral is expired, the Dr’s at Rockhampton Eye Clinic will not be able to see you until a valid referral is provided.