New Patient Form

Patient Information

1. PATIENT DETAILS

Title*

Given Name*

Surname*

Date of Birth*

Age*

Height*

Weight*

Occupation*

Address*

Postcode*

Mobile*

Alternative Phone Number

Email Address*

Medicare Number*

Reference Number*

Private Health Fund

Membership Number

Pensioners Card No. (if applicable)

Expiry Date

Department of Veterans’ Affairs No (if applicable)

Colour

WorkCover or TAC (if applicable)

Claim Number

Date of Injury

Insurance provider (e.g. Allianz or CGU)

2. EMERGENCY CONTACT

Next of Kin (name):

Relationship

Next of Kin Mobile

3. REFERAL DETAILS

Name of Doctor who has referred you today*

Referring Doctor Clinic Name & Address*

Usual GP (if different to above)

Usual GP Clinic Name & Address

Are you seeing any other Specialist (name & clinic)

Do you have a usual Physiotherapist (name and clinic)

Have you had Radiology Imaging done (Type of scan and radiology clinic name)

4. MEDICAL HISTORY

Do you have any allergies or previous reactions to medicines, latex, dressings, food or anything else?

Have you had a steroid or other injection (s) to a joint?

Which Joint

Date of Injection

List Current Medications (including semaglutide medication such as Ozempic®, Wegovy® or Mounjaro®)*

List All Medical Conditions*

List Surgery (past or planned)

Have you been in hospital outside of WA or overseas in the last 12 months?

5. CONSENT

New Consultation $250.00 | Subsequent Consultations $120.00 | TAC First Appointment $300.00

CONSENT: I provide my consent for my surgeon to collect, use and disclose my personal information as required by the Privacy Act 1988 and my consent for them to collect, use and store clinical images for the purposes of my clinical care (including x-rays, intra-operative images and clinical images). I also provide authorisation for the Practitioner to claim the rebate amount of my consultation direct from Medicare, should my account remain unpaid.

Any expenses, costs or disbursements incurred by the Practice in recovering any outstanding monies, including debt collection agency fees and solicitors costs, shall be paid by the Patient providing that those fees do not exceed the scale of charges as charged by that debt collection agency/solicitor.

Signature*

Date*