New Patient Registration Form

Please complete this online form prior to your first visit with us.

PATIENT DETAILS

 

MrMasterMrsMsMissDrOther

Surname *

First Name *

Preferred Name

Date of Birth *

Address *

City / Suburb *

State *

Postcode *

Home Phone

Mobile Phone *

Work Phone

Email *

Occupation *

NEXT OF KIN CONTACT DETAILS

Next of Kin - Name *

Next of kin - Email *

Contact Number *

Relationship to Patient *

EMERGENCY CONTACT DETAILS

Surname *

First Name *

Contact Number *

Relationship to Patient *

REFERRING DOCTOR TO US

Referring Doctor’s Name *

Address *

Practice Name *

Phone Number *

FAMILY DOCTOR (if different to referring doctor)

Family Doctor

Address

Practice Name

Phone Number

MEDICARE

Medicare Card No. *

Ref No. *

Expiry *

Pension Care No.

Pension Care Expiry

Healthcare Card No.

Healthcare Card Expiry

DVA Number

Colour

Conditions

DVA Expiry

PRIVATE HEALTH INSURANCE

Do you have private Medical insurance

YesNo

Private Health Fund Provider

Membership No.

ACCOUNT RESPONSIBILITY

Account Responsibility *

SelfParentDVAWorkcoverCTP

Other Insurance (eg. Sports Insurance)

Claim Number

Case Manager Name

Contact Number

Insurer Email

MEDICAL HISTORY

Medical History

Heart DiseaseHigh Blood PressureType 1 DiabetesType 2 DiabetesGestational DiabetesCOPD/EmphysemaCancerDeep Vein Thrombosis DVT - Blood clot in legPulmonary Embolism - Blood clot in lungsHIVHepBHep CSmokerDrink Alcohol Daily Depression  EpilepsyAsthma

Other Condition

Please specify what type of Cancer

Please list any previous surgeries you have had (please include site of surgery, date of surgery and related issues or complications)

Please list any current medications you are taking (please include the name, dose and frequency)

Please list any known allergies that you may have (please include what you are allergic to and the reaction)

MEDICAL DECLARATION & CONSENT

As a patient we require you to provide us with accurate details in order for us to provide you with adequate information to assist in your orthopaedic needs. We are committed to protecting your privacy and health information obtained during the consultation and treatment process. These details are collected to ensure a high quality of care. The information obtained may be disclosed to other health professionals involved in your care.

Please read the following statements before signing below (Please tick):

I declare, that to the best of my knowledge, the information supplied on this document is true and accurate.

I agree to my medical information being shared with my treating medical and allied health team, where appropriate.

I allow, Dr Amaranath, to use deidentified data, scores and clinical photography, that is information that does not identify you, for research, education and quality improvement activities.

Patient/ Guardian Signature

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Name (please print)

Today's Date

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