New Patient Registration and Consent Form

Welcome to the practice of Dr. Benjamin Kenny. Our aim is to provide you with the best possible healthcare.

Please complete all sections and read the Personal & Health Information Consent section at the end of this form.
Please discuss any queries with our reception staff or with Dr. Kenny.


  • We want to provide the best health care possible. Many patients find it valuable to correspond by email and SMS. These SMS and emails will contain some of your health information, however they are not a secure method of communication. If you DO NOT want to correspond via email or SMS then please tick this box.
  • Medical History

  • What are your current or past health issues? Please mark and provide details.

  • Medications

    Prescription and over the counter
  • eg. Warfarin, Asprin, Dabigatran, Clopidogrel.
  • Personal & Health Information Consent

  • We respect your right to privacy and take our privacy obligations seriously. We comply with the Australian Privacy Principles, found under the Privacy Act 1988 (Cth). Our Privacy Policy can be obtained from Reception. We require your consent to collect personal information and health information about you. Please read this information carefully, and sign where indicated below. Dr. Benjamin Kenny collects information from you for the primary purpose of providing your orthopaedic services. We require you to provide us with your personal and health information including your full medical history so that we may provide our services to you. We will also use the information you provide in the following ways:
    • appropriately manage our practice, such as conducting audits and undertaking accreditation processes, manage billings and training staff
    • effectively communicate with third parties, including Medicare Australia, private health insurers, government departments and other practitioners involved in your healthcare.
    I have read the information above and understand why my information is collected and how it is used. I acknowledge that I am not obliged to provide any information requested of me, but that failure to do so might compromise the quality of care provided to me. I understand that email and SMS are not a secure form of communication. I acknowledge that email and SMS will contain some of my health information and I consent corresponding via these methods.