Julian Yu Patient Registration

DR JULIAN YU
BMed FRACS (Orth) FAOrthA
CONSULTANT ORTHOPAEDIC SURGEON
SPECIALIST HIP AND KNEE SURGEON

PATIENT REGISTRATION AND INFORMATION FORM

Date

Title *

Other Title *

Given Name(s) *

Last Name *

Date of Birth *

Occupation *

Age in Years

Address *

Suburb *

Postcode *

Phone *

MobileHome Phone

Mobile

Home Phone

Email Address *

Referring GP *

Usual GP Details (if different from above)

Other health professionals you want included in correspondence e.g. Physio/Chiro

EMERGENCY CONTACT INFORMATION

Name *

Relationship *

Phone / Mobile *

MEDICARE / HEALTH INSURANCE INFORMATION

Medicare Number *

Number Next to Your Name *

Expiry

Pension Concession Card *

YesNo

Blue Card Holders Only

Pensioner Number *

Expiry *

If patient is under 14 or parent wants to claim rebate on own account – please complete following details

Parent Name

Parent DOB

Number Beside Nameof Parent on Medicare Card

Private Health Fund *

Membership Number *

DVA Card Type *

WhiteGold

DVA Number *

Claim Number *

Provider *

Claim Manager Name *

Claim Manager Contact Number *

AUTHORISATION FOR RELEASE OF INFORMATION & PAYMENT INFORMATION

It is the usual practice for us to write to your referring doctor and any specialists involved in your care. Furthermore, it may be necessary to write to yourWorkers Compensation, 3rd Party or rehabilitation provider.

You will receive a rebate from Medicare to assist in the consultation fees and/or operative fees. This amount depends on the financial arrangements made. Ultimately you (or your guardian) are responsible for the account.

I understand and agree that payment is required at the time of consultation and I am responsible for payment of all charges includingthose not fully paid by my insurance / workcover company

I agree *

Date

Full Name *

Signature *

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