Ear tag excision registration form

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Help us provide your child with excellent care: Please read and complete this form

How we handle your child's information

Dr Jill Tomlinson collects the personal and health information in this form to provide and manage your child's surgical and medical care.

Providing this information is voluntary. If you do not provide it, we may be unable to provide your child's care or process your request.

Your child's information is entered into our clinical records, which are held in Victoria, and a copy is emailed to our practice inbox in Sydney. The copy stored on this website is deleted, generally within 5 days. Backups of the website are stored in Singapore, and website traffic may pass through servers outside Australia via our content delivery network.

We may share your child's information with others involved in their care, including their GP, referring doctor and hospitals, and, for billing, Medicare and your health fund. We handle health information under the Privacy Act 1988 (Cth) and the Health Records Act 2001 (Vic).

Our Privacy Policy explains how we handle your child's information, how you can access or correct it, and how to make a complaint.

Contact: info@jilltomlinson.com | 03 9427 9596

Do you have an existing appointment booked at our clinic?

yes

no, please contact me via phone to discuss

no, please email me with appointment options

no, I will contact your office

Appointment preferences

Preferred days

Monday

Tuesday

Thursday

No preference

Which days suit you? (select all that apply)

Preferred time of day

Morning (9am to 12pm)

Early afternoon (12pm to 2:30pm)

Late afternoon (2:30pm to 4:30pm)

No preference

Optional notes

Anything else we should know about your availability?

Your baby's information

Baby's Name

Title Given name(s) Preferred name Surname

Date of Birth(Required)

Day

Month

Year

Home phone

Tick here if you have not yet received your child's Medicare details

I have not yet received my child's Medicare details

Medicare number

Enter Medicare number (no spaces needed)

Medicare reference number

Please enter a number from 1 to 9.

Month

Medicare expiry month

Year

Medicare expiry year

Do you need an interpreter?

yes

What language interpreter do you require?

With adequate notice, we can organise a TIS Online video interpreter for eligible appointments. If you access an Auslan interpreter through NDIS funding, please continue to arrange this as you normally would.

Address

Street Address

Address Line 2 (optional)

Suburb

State

Postcode

Parent information

Parent 1(Required)

Prefix First Last

Parent 1 mobile phone(Required)

Parent 1 email(Required)

Parent 2

Prefix First Last

Parent 2 mobile phone

Parent 2 email

Because your child is under 12 years of age

When a child is under 12, we require the parent or guardian’s Medicare details in order to submit the claim to Medicare on your behalf and process your rebate. We therefore request that you provide the following details for the parent or guardian who is listed 1st on the Medicare card: - Medicare card number - Full name - Date of birth - Medicare card expiry date

Full name of the Parent listed #1 on the Medicare card

Date of Birth of the Parent listed #1 on the Medicare card

Day

Month

Year

Medicare number

Enter Medicare number (no spaces needed)

Month of expiry

Medicare expiry month

Year of expiry

Medicare expiry year

Referral information

General practitioner (if not your referring doctor)

General practitioner's address (if not your referring doctor)

Referral (if not already provided)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, docx, doc, Max. file size: 256 MB.

Please upload at least two clear photographs of each ear that has an ear tag

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 256 MB.

Please upload at least two clear photographs of each ear tag. We require these before we confirm a telehealth appointment for you. If you can take each photograph from a different angle this better allows Dr Tomlinson to assess the size and makeup of the ear tag.

Medical history

Allergies

List any known allergies

Medications

List any regular or commonly taken "as needed" medications

Medical conditions

This allows you to provide more detailed important information about your baby's general health, if you feel this is needed

This field is hidden when viewing the form

Infant Ear Tag Excision: Preappointment Information

Ear Tag Excision – Pre-appointment Information

Dr Tomlinson has prepared a short video for parents to watch before the consultation. It explains what an ear tag is, how the excision procedure is performed, and what to expect on the day and during recovery.

Watching this video in advance will help you understand the process and make the most of your appointment.

▶ Watch Pre-appointment Video

If the video does not display above, please use the button to view it on our website. The video will open in a new tab.

Consents and acknowledgements

Please read the following information carefully before proceeding. Your acknowledgements are required for us to provide your care.

Privacy & Collection of Health Information

Dr Jill Tomlinson collects personal and health information that is necessary to provide your child with medical assessment, treatment, surgical care, and associated administrative services.

This information may include:

Contact and identification details
Medicare, TAC, or private health insurance information
Medical history, medications, allergies, and investigation results (including imaging and pathology)
Referrer details and clinical correspondence

Your child's information is collected directly from you where possible, and may also be obtained from your referring practitioner, other treating health professionals, hospitals, imaging or pathology providers, Medicare, insurers, or other third-party payers involved in your child's care.

Your child's information may be used and disclosed for the purposes of:

Providing medical assessment, treatment, and follow-up care
Communicating with your referring practitioner and other relevant health professionals
Arranging hospital admission and surgical care
Billing Medicare, TAC, private health insurers, or other third-party payers
Practice administration, accreditation, and quality assurance activities

Our practice complies with applicable Commonwealth and Victorian privacy legislation, including the Privacy Act 1988 (Cth) (including the Australian Privacy Principles), the Health Records Act 2001 (Vic) (including the Health Privacy Principles), and where relevant, the My Health Records Act 2012 (Cth).

Our Privacy Policy explains how we handle your child’s information, how you can access or correct it, and how to make a complaint.

Privacy Consent(Required)

I have read the collection statement and Privacy Policy, and I consent to the collection, use and disclosure of my child's personal and health information as described for the purposes of medical care, coordination of care, and associated administrative and billing functions.

Financial Responsibility

Consultation fees are payable on the day of your child's appointment unless prior arrangements have been made.

You acknowledge and agree that:

Medicare rebates are set by Medicare and are not controlled by this practice.
Private health insurance rebates vary depending on your level of cover and insurer. They do not apply to outpatient consultations or procedures.
You are responsible for any gap fees, excess payments, or costs not covered by Medicare or your private insurer.

If hospital surgery is recommended, you will be provided with a written estimate outlining surgeon, assistant, anaesthetist, and hospital fees prior to proceeding.

Failure to attend a scheduled appointment without adequate notice may result in a cancellation fee in accordance with our cancellation policy.

Financial Responsibility Acknowledgement(Required)

I confirm that I have read and understood the Financial Responsibility information and agree to be responsible for all applicable fees, including any gap payments, and to comply with the practice’s payment and cancellation policies.

Assignment of Medicare and Insurer Benefits

Where applicable, you authorise Dr Jill Tomlinson to submit claims to Medicare or your private health insurer on your behalf for services provided.

You consent to the assignment of benefits payable for these services to Dr Jill Tomlinson, including for consultations and, where relevant, surgical procedures.

You acknowledge that you remain responsible for any fees not covered by Medicare or your private health insurer.

Medicare / Insurer Assignment Consent(Required)

I authorise Dr Jill Tomlinson and her practice to submit claims to Medicare or relevant insurers on my child's behalf where applicable.

Electronic Communication

The practice may communicate with you via email or SMS regarding appointments, results, invoices, and clinical correspondence.

While reasonable steps are taken to protect your privacy, electronic communication carries inherent risks, including potential unauthorised access, delay, or non-delivery.

You are responsible for providing accurate contact details and notifying the practice of any changes.

Electronic Communication Consent(Required)

I confirm that I have read and understood the Electronic Communication information and consent to being contacted by email and SMS for the purposes outlined.

Digital Documentation Assistance (Heidi Health)

Dr Jill Tomlinson uses a secure digital scribe system (Heidi Health) to assist with documenting consultations. This tool allows your clinician to focus on your child's care while accurately capturing clinical information.

Purpose

Heidi Health is used solely to create accurate and complete medical records. It supports your child's clinician but does not replace professional judgment; all medical decisions are made by your child's clinician.

How Your Data is Handled

Data is processed and stored in Australia in accordance with Australian privacy laws and the Privacy Act 1988 (Cth).
No audio recordings are stored. Conversations are transcribed in real time, and only the clinician-reviewed transcript is retained temporarily for inclusion in your medical record.
Your data is securely encrypted, access is strictly limited to your clinician, and regular audits are conducted to maintain compliance with global standards (SOC 2, ISO 27001).
Data is not used for secondary purposes, and identifiers are removed for any de-identified use.

Your Rights

You can choose to opt-out of using Heidi Health during your child's consultation at any time.
Withdrawing consent will not affect the quality of care your child receives.
You have the right to access the information collected about your child, except where access may be lawfully restricted.

More information about Heidi Health can be found at heidihealth.com.

Digital Documentation Assistance Consent(Required)

I confirm that I am the parent or legal guardian of the patient and have read and understood the Digital Documentation Assistance (Heidi Health) information. I consent to the use of Heidi Health to assist my child's clinician with accurate documentation of my child's consultation, and I understand I may withdraw this consent at any time without affecting my child's care.

Clinical Photography

Clinical photographs may be taken as part of your child's care. These images assist in assessment, treatment planning, monitoring progress over time, and evaluating outcomes.

Photographs may also be used to communicate with other health professionals involved in your child's care, and in de-identified form for education and research purposes.

All images are handled in accordance with the Privacy Act 1988 (Cth) and the Health Records Act 2001 (Vic).

You are not required to consent to all uses of your child's photographs. You may place restrictions on how your images are used.

Photography Acknowledgement(Required)

I confirm that I am the parent or legal guardian of the patient, have read and understood the Clinical Photography information, and consent to the taking and use of the patient’s clinical photographs, subject to any restrictions specified.

Restrictions on Use of Clinical Photographs

You may place restrictions on how your child's clinical photographs are used. If you choose to opt out of certain uses, you acknowledge that:

You have read and understood the information above regarding clinical photography.
You have received an explanation of why clinical photographs may be taken.
This practice has a privacy policy governing the handling of clinical images.
You are not obliged to consent to clinical photography; however, in some circumstances this may limit the assessment, treatment, or documentation that can be provided.
You have the right to access your child's information, except where access may be lawfully restricted, in which case an explanation will be provided.
Your child's photographs will not be used for purposes outside those described without your consent.

I confirm that I am the parent or legal guardian and wish to place restrictions on the use of my child's images

Do not include photographs in my child's medical record as part of my child's treatment

Do not share my child's photographs with other health professionals involved in my care

Do not use my child's photographs in de-identified form for education and training

Do not use my child's photographs in de-identified form in research publications (including journal articles or book chapters)

Do not use my child's photographs in de-identified form on practice websites for patient or parent education

Do not use my child's photographs in de-identified form on practice social media for patient or parent education

What happens next?

After you submit this form, you will be taken to a confirmation page.
You will receive a confirmation email with a copy of the details you have provided for your child attached as a PDF.
For your child’s privacy and security, the PDF is password protected. If you would like to access it, please contact our office and we will be happy to assist you.
The information you provide will be securely sent to our office and added to your child’s clinical information system record.

If you do not receive your confirmation email within a few minutes, please check your junk or spam folder, as it contains important information.

If you are still unable to locate the email, please contact our office for assistance.