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Dr Maree Kekeff • Gold Coast Breast Centre
256-bit Secure Confidential Form

New Patient Information & Photo Consent

Please complete all relevant sections prior to your appointment.

Gold Coast Breast Centre provides facilities and administrative support. Dr Maree Kekeff is an independent practitioner and is responsible for her own clinical records and fees.

1. Patient Information

Fields marked with an asterisk (*) are mandatory.

Residential Address

Contact Information

Would you like to receive occasional emails with updates, health tips, and clinic news? Your information is kept confidential and you can unsubscribe at any time.

Medicare & Concessions

Private Health Insurance

Emergency Contact

Next of Kin

2. Medical History

This information assists Dr Maree Kekeff in planning your care safely and effectively.

• BreastScreen Queensland:
Only complete this form if you have had an appointment at BreastScreen Queensland (the public breast screening service). BreastScreen Queensland Image Request →
• Prior Medical Records:
If there are any medical records or surgery information you would like us to have, please fill out: Request For Medical Records →

Please indicate which of the following is relevant to your medical history:

Cardiovascular Conditions
Chest Conditions
Other Conditions

3. Consent to Collect Patient Information

The information requested in this form and relevant health information may be sent to other health professionals (e.g. your anaesthetist) or organisations (e.g. hospitals, pathology) where this is needed to provide your healthcare.

As required by the Privacy Act 1988 (Cth), Gold Coast Breast Centre and Dr Maree Kekeff request your consent for the collection, use and disclosure of your personal and health information for the purposes set out below:

  • Administrative and billing purposes, including compliance with Medicare Australia requirements.
  • Contacting you, or your next of kin, for recalls and reminders, and your emergency contact in case of emergency.
  • Disclosure to other health professionals involved in your care, including referring doctors, hospitals and specialists.

As a patient you have the right to experience a high standard of care. If you feel this standard has not been met, you can discuss this directly with Dr Maree Kekeff or the Gold Coast Breast Centre Practice Manager, or you can contact AHPRA or the Office of the Health Ombudsman.

Clinical images

Clinical images are a standard part of consultations and surgery. With your consent, these images become part of your patient record and are used for ongoing treatment purposes only. Any other use of your images (such as teaching or marketing) is optional and is covered separately in the Photo Consent at the end of this form. Please speak to Dr Maree Kekeff if you have any concerns.

AI transcription (optional)

With your permission, Dr Maree Kekeff may use an AI transcription tool during your appointment. It transcribes the conversation as it happens to help draft your clinical notes and letters. Audio recordings are not stored. Dr Maree Kekeff reviews the draft and decides what is saved to your health record. Your information is processed and stored in Australia and handled in line with the Gold Coast Breast Centre Privacy Policy.

This is your choice. If you say no, or change your mind at any time, including during an appointment, your care will not be affected and Dr Maree Kekeff will take notes as usual.

Consultation Costs and Medicare Rebate:

Dr Maree Kekeff sets her own fees and cancellation terms. These are not set by Gold Coast Breast Centre. You are only entitled to a Medicare rebate if you have a valid referral.

  • • Initial consultation: $330.00 (Medicare rebate: $88.40)
  • • Review appointment: $180.00 (Medicare rebate: $44.45)
Deposit and Cancellation Policy: To secure your consultation, Dr Maree Kekeff requires a $100 deposit. If your appointment is cancelled with less than 2 business days’ notice, the deposit is non-refundable.
I consent to transcription software being used to create notes and letters during my appointments (more information can be provided to you) *

By signing this form, I acknowledge that I have read and understood the information above.

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Final Section

Photo Consent: optional uses of your images

Clinical images taken for your medical record are covered by your consent earlier in this form. This form asks separately whether you agree to your images being used in other ways. Each choice is optional, and saying no to any or all of them will not affect your care.

  • Dr Maree Kekeff takes reasonable steps to remove identifying features such as your name, face and tattoos, but cannot guarantee that you will not be recognised.
  • Images are stored securely in Australia in line with the Australian Privacy Principles. They are accessed only by Dr Maree Kekeff and staff. They will not be sold or transferred to any other person or organisation for purposes you have not agreed to.
  • You will not receive payment from any party for the use of your images.

Please read this information carefully. If you have any questions, contact Dr Maree Kekeff's Practice Manager.

By signing this form, I confirm that:
  • I grant permission for images of me to be used only in the ways I have selected below.
  • I am at least 18 years of age, I have read and understood this form, I have not been offered any inducement to give permission, and I am able to give this consent.
  • This form has been explained to me in terms I understand.
  • I understand that I can withdraw my consent at any time by contacting Dr Maree Kekeff's Practice Manager. If I withdraw, Dr Maree Kekeff will stop further use of my images and remove them from her website and social media where possible. Images already published in journals or textbooks, or already shown in teaching, cannot be recalled.
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Format: DD/MM/YYYY