PATIENT REGISTRATION

Title *

First Name *

Middle Name

Last Name *

Date of Birth *

Gender *

FemaleMale

Occupation *

Hand Dominance *

RightLeft

Identification *

AboriginalTorres Strait IslanderBothNeither

Address *

Suburb *

State *

Postcode *

Contact Number *

Email Address *

Emergency Contact Name *

Relationship *

Contact Number *

Medicare Number *

Medicare Reference *The number next to your name

Medicare Expiry *

Health Fund Name *Write NONE if not applicable

Health Fund Number *Write NONE if not applicable

DVA Card Number

Worker's Compensation

Is this a Worker's Compensation case? *

YesNo

Claim Number

Insurer

Case Manager Name

Case Manager Contact

Referring Doctor

Referring Doctor Name *

Referring Doctor Address *

Suburb *

State *

Postcode *

Is your GP the same as your referring doctor? *

YesNo

GP

GP Name

GP Address

GP Suburb

State *

Postcode

Privacy Policy

Click here to read our Privacy Policy

I have read and agree to the Privacy Policy *

Conditions

I provide consent for specialists and practice staff to access and use my personal information to provide me with the best possible healthcare.

I give permission for correspondence to be sent to my referring doctor, general practitioner, physiotherapist and insurance company where appropriate.

I undertake to pay all fees owing to my Surgeon, including in the event that liability is denied or any outstanding accounts that have not been paid in full by my insurer.

I also understand that any outstanding monies requiring debt recovery will incur Debt Recovery fees and I will also be responsible for any legal costs incurred.

I have read and agree to the Conditions *

Signature *

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