Validus Medical Australia

REGISTRATION DETAILS FORM

Welcome , ()

Please fulfill all mandatory fields (marked with *)

Patient Information
User Name (Entered on previous registration screen) *

Patient's First Name *

Patient's Last Name *

Gender: M F

Date of Birth (DD/MM/YYYY)

Permanent Address *

City *

State / Province *

Country *

Zip or Postal Code *

Home Telephone *

Business Telephone:

Email Address: *

Do you have an Intended Local Address?

Intended Local City

Intended Local State / Province

Intended Local Country

Intended Local Zip or Postal Code

Local Telephone: (if available)

Local Fax:

Emergency Contact Name:

Contact's Telephone Number:

Clinical Information
Patient Diagnosis:

Patient Clinical Status:

Clinical Department or Specialty

Anticipated Travel Dates to Australia:
Arrival Departure

Referral Information

Who recommended our services to you?
Relative/acquaintance/friend
Insurance Company
Embassy
Employer
Other, please specify:

Please check one:
Self-Referral Physician Referral

Referral request: *
2^nd Opinion Physician Consultation Hospital Admission Other

Referring Physician
Agent Government Insurance Company Employer

Name *

Referrer's Business Name

Referrer's Business Address

Office Telephone Number *

Fax Number

Emergency Telephone Number

E-mail Address *

Patient Services Information

Will you need assistance with the following?

Interpreter Services: * Yes No

Languages you speak:

Hospital Accommodation Preference: Private Room Semi-private room

Will You Need Hotel Accommodation? Yes No

Number of guests traveling with you *

Number of rooms needed

Hotel rating preference

Transportation from Perth International Airport to hotel or hospital: Yes No

Special diet during your hospital stay: Yes No

If yes, please specify diet:

Do You Require a Visa? *
Yes No

A Visa is required if the patient is travelling to Australia. [Download Visa Application]

Has Medical Treatment ever been denied to you? *
Yes No

If yes, please specify why

Any Other Questions?

Privacy Statement
Validus recognises that its clients will provide sensitive and confidential information in the process of using our services and is committed to protecting your privacy. Validus is bound by and complies with the National Privacy Principles (NPPs) as stated in the Commonwealth Privacy Act 1988 (Cth) ("Privacy Act"). Under the Privacy Act 1988, 'personal information' is generally information about an individual from which their identity can reasonably be determined. Validus limits access to client details to authorised personnel who are trained in the proper handling of confidential information. Validus and Your Privacy Validus offers overseas clients access to the quality health care services available in Western Australia. Validus manages all arrangements from the time of initial enquiry to eventual return home and offers the most relevant options following careful discussion and determination of the patient's needs. The medical and health care services are delivered through our service partners and affiliates. Your Personal Information Validus obtains personal information from you in order to facilitate and coordinate the services that you request. Personal information may include, but is not limited to: - Your name and address - Your date of birth - Passport and travel details - Contact details, telephone, mobile and email address - Bank account and or credit card details - Medical information (as per patient consent form) - User name and password (via login features) - Personal data left or sent via the website If you do not provide us with certain personal information (eg date of birth, medical details), we may not be able to appropriately arrange the services you require. You may also need to supply personal information about other individuals to Validus (such as travelling companions or your authorised delegate). If this is applicable, we rely on you to inform the appropriate individuals that you are providing their personal information to Validus and advise them that we may be contacted for further information. How we collect Personal Information Validus collects personal information by the following methods: - - Directly from you, when you provide information by telephone or personal contact - By completing forms on-line via the website (contact us page, member logins) or by email or postage - From third parties, (such as your authorised agent or translator/interpreter, medical provider, service provider) - Through an Validus representative in a local office - When legally required to do so, (visa or credit conditions) - Invoices, billing and payments - Surveys, written, online or telephone How we use your Personal information The primary purpose for using your personal information is to supply you with services (non-medical, travel, accommodation, concierge,) that you have engaged us to provide for you. - Deliver services requested by you - Verify your identity for security reasons - Book services required by you through our partners/service providers/affiliates - Assist you to subscribe to our services or through website logins - Administer and manage those services, including deposits, billing, payments - Conduct appropriate credit checks for payment or validate funds available for services, (eg visa application) - To comply without legal obligations - Attain an understanding (through surveys) to improve our services How we disclose your Personal Information To provide you with the services you request when completing or accepting a quotation or enquiry form, Validus may disclose your personal information to our partners/service providers/affiliates. Your personal information is disclosed in these scenarios to our partners/service providers only in relation to Validus delivering our services to you. Validus takes reasonable care to ensure that our partners/service providers/affiliates are bound by confidentiality and privacy obligations in regards to protecting your personal information. Validus Website Validus presents information, products and services through our website. When you utilise our site, the web server records the details of the time, date and URL of the request. The information is used to augment and develop the configuration of our site and monitor ongoing website performance. Validus may use 'cookies' on this web site. Cookies are an industry standard and most major web sites use them. A cookie is a small text file that our web sites may place on your computer. Usually, cookies are used as a means for our web sites to remember your preferences. As such, cookies are designed to improve your use of our web site. In some cases, cookies may collect and store personal information about you. Validus extends the same privacy protection to your personal information, whether gathered via cookies or from other sources. You can adjust your Internet browser to disable cookies or to warn you when cookies are being used. Please note that if you disable cookies, you may not be able to access certain areas of our web site. Validus also collects Internet Protocol (IP) addresses. IP addresses are assigned to computers on the internet to uniquely identify them within the global network. Validus collects and manages IP addresses as part of the service of providing Internet session management and for security purposes. Links This website may contain links to other sites. The 'privacy policies' at these other sites may be different from this policy. Those sites' 'privacy policies' will govern the use of information you provide to them. Sensitive Information Validus may collect personal information that is 'sensitive information', and may relate to health or medical details (for example, medical reports). Sensitive information will be used or disclosed only for the purpose for which it was given and forwarded directly to the party it is intended for or as required by law. Where medical information is required to be transferred to a third party, this will be in conjunction with the completion of the appropriate consent form which authorises the release of medical information. Holding accurate Information Validus takes all practical precautions to ensure that the personal information we collect, use and/or disclose is complete and correct, however, the accuracy of the information is subject to the accuracy of the details you submit. Please advise us if there is any omissions or errors in your personal details or if there are changes to your personal information or contact particulars. If you have a login or subscribe to any feature through the website, then you may change or update your information when you use the website. Management of Personal Information Validus takes reasonable measures to protect the security of personal information. We respect the confidentiality of personal information and the privacy of our clients. Validus takes steps to protect personal information it holds from misuse and loss and from unauthorised access, modification or disclosure, (by use of physical security and restricted access to electronic records). Where we no longer require your personal information we will take the appropriate measures to destroy it. Please protect your login and password access to the website, where utilized, to ensure that your personal information is kept secure. Updates to this Policy This Policy may be reviewed from time to time to take account of new laws and technology, changes to our operations and practices and changing business conditions. The website will be updated accordingly if there are any changes or modification to the policy. Accessing your Information You have the right to access your personal information that is held by us, subject to some exceptions allowed by law. For security reasons, we require you to make any request for access to your personal information in writing. Validus reserves the right to charge a fee for searching and providing access to your information. We will advise you of the fee when you apply for access. How To Contact Us: Validus Medical Australia Pty Ltd Southbank Central Suite 6, 38 Meadowvale Avenue South Perth Western Australia 6151 Phone: +61 8 9423 0999 Fax: +61 8 9474 5098 Email: admin@validus.com.au

I have read and understand Validus Medical Australia's Privacy Agreement *

PLEASE BE SURE TO REVIEW YOUR SELECTIONS CAREFULLY PRIOR TO SUBMISSION TO VALIDUS. WE LOOK FORWARD TO ASSISTING YOU, AND ASK THAT YOU PROVIDE AS MUCH OF THE REQUESTED INFORMATION AS POSSIBLE SO THAT WE MAY SERVE YOU BETTER.