PAEDIATRIC HEARING ASSESSMENT

PRE-APPOINTMENT QUESTIONNAIRE

Background Details

Child's First Name *

Child's Last Name *

Child's Date of Birth *

Child's age

Child's Gender *

MaleFemaleOther

Parent/Carer Mobile Phone Number *

Parent/Carer Email Address *

Address *

Street address

Suburb

State

Postcode

GP's Name

GP Practice Name

Medicare

Parent's Medicare Number *

Child's Reference Number on the Card (e.g. 1, 2) *

Medicare Expiry Date *

Parent's Date of Birth for Medicare Billing *

Parent's Full Name as on Medicare Card *

Clinical Concerns

What do you think about your child's hearing?

GoodPoorUnsure

Please comment on your child's hearing/listening

Is your child prone to recurrent ear infections/other medical illnesses?

YesNoUnsure

Please comment on your child's overall health

Do you or others find it difficult to understand what your child says?

YesNoChild not speaking yetUnsure

Please comment on your child's spoken language

Does your child find it difficult following spoken directions?

YesNoToo young to follow directionsUnsure

Please comment on your child's understanding of spoken language

Does your child have any known medical conditions/developmental diagnosis?

YesNoUnsure

Please list diagnoses if applicable

Referrer Details

Who referred your child to SASHC?

If other, please comment

Collection Statement

Allied Health Services

SASHC is required to collect and record personal information about you and your child in order to provide quality allied health services. This may include assessing, diagnosing and providing therapy. This information is relevant to your child’s situation, such as your child’s name, contact information, medical history and other relevant information as part of providing services to you. This collection of personal information will be a necessary part of the assessment and/or treatment that is conducted.

Purpose of Collecting and Holding Information

All personal information gathered as part of your child’s assessment and treatment, is kept securely. In the interest of your child’s privacy this information is only used by your child’s therapist/s and authorised SASHC staff . Your personal information is retained for record keeping purposes and enables your child’s therapist to provide a relevant and informed service to you/your child. A more detailed description is provided in the SASHC “Privacy Policy”. This policy is available to you on request.

Access to client information

At any stage you are entitled to access your child’s personal information kept on file, subject to exceptions in the relevant legislation. SASHC will discuss with you your different possible forms of access.

Disclosure of personal information

All personal information gathered by SASHC during the provision of allied health services will remain confidential, however, please note that by signing and acknowledging this document, you accept that information will be shared with other allied health professionals involved in your child’s care.

Please notify us if you do not wish us to disclose this information or if a child protection/court order is in place.

Audio/Video Recording

As a therapeutic clinic, we often make recordings of sessions and assessments for both analysis and planning. We may also utilise some of these recordings for teaching purposes. Your recordings will be kept secure and will not be shown to individuals not associated with our practice/clinic.

On behalf of SASHC, we undertake that, in respect of any audio/video recordings made, every effort will be made to ensure professional confidentiality and that any use of these audio/video recordings, or descriptions of audio/video recordings will be for professional use only and in the interest of improving professional standards through research and training programmes. Every effort will be made to ensure the anonymity of all those involved in the session.

Do you agree with the audio/visual statement above? *

YesNo

Media Release

We occasionally take photos during sessions for educational, promotional, and social media purposes. These images may include identifiable details such as your face and name, and may be used on our website, social media platforms, and in other promotional materials.

Do you give consent to photos being taken and used as above? *

Yes, I give consent to the use of my/my child's photosNo, I do not give consent to the use of my/my child's photos

Cancellations

Self-funded appointments

A cancellation fee of $50 is payable upon any appointment cancelled within 48 working hours (2 business days) of the scheduled appointment. We will make every effort to send out reminders for upcoming appointments, however it is your responsibility to inform us if you cannot make these appointments.

No shows will be charged 100% of the appointment cost.

NDIS appointments

We understand that at times appointments will need to be cancelled due to illness and unavoidable circumstances. However, in order to provide an affordable and viable service, SASHC has adopted the following cancellation policy in line with NDIS policy.

We will send out reminders for all scheduled appointments, however, no shows and appointments cancelled within the short notice period (defined by the NDIS as less than 2 clear days) from the scheduled time will incur a fee of 100% of the agreed fee associated with the activity from the Participant's plan.

Late attendance

We make every effort to send out appointment reminders, and we ask that you respect our clinicians time. Arriving late not only impacts your appointment but also those of other patients scheduled throughout the day. Consequently, we are unable to complete full assessments for late arrivals. Therefore, patients who arrive 10 minutes or more past their scheduled appointment time will not be seen and a full appointment fee will be charged.

Fees and Rebates

Fees Payable

If you are a Medicare client, you are required to pay the fee in full on the day of the appointment. Your rebate will be processed through MEDICARE and will be deposited into your nominated bank account within 24 hours of service if you are registered with MEDICARE for rebates.
All private health rebates will be made through HICAPS on the day of the appointment.
If you are an NDIS participant and the NDIA does not pay any account associated with the service provided you will be legally responsible to pay SASHC for the unpaid accounts.
Reports of any type will not be released without prior payment.

Consent

I (please print name) *

have read, understood and agree to the above conditions, and as the authorised person, agree to the provision of services by SASHC.

Relationship to the child

Signature *

Draw signature|Type signatureClear

Date *