PATIENT REGISTRATION Part 1

Title *

First Name *

Middle Name

Last Name *

Full name of parent in case of minors

Address *

Suburb *

State *

Postcode *

Email Address *

Please tick if you do not want to receive our newsletter

Sex *

FemaleMale

Date of Birth *

Occupation *

Home

Work

Mobile

Please enter at least one phone number to continue

NEXT OF KIN

Name *

Relationship *

Contact Number *

HEALTH INSURANCE

Private Health Insurance *

YesNo

Health Fund Name

Membership Number

Aged Care Pension *

YesNo

Pension Number

Expiry Date

Medicare Number

Position on Card

Veterans Affairs Card Number

DVA Card Colour

GoldWhite

Accepted Condition

Referring Doctor's Name *

Address *

GP is the same as referring doctor *

YesNo

GP Phone Number *

GP Name

Address

WORKERS COMPENSATION

Is this a Workers Compensation claim? *

YesNo

Employer (if applicable)

Date of Injury

Employer Address

Employer Phone

Solicitor Name and Address (if applicable)

Insurance Company Name and Address

Claim Number

Case Manager Name

Case Manager Phone

Case Manager Fax

CONSENT FORM

We require your consent to collect personal information about you. Please read this information carefully, and sign where indicated below.

This medical practice collects information from you for the primary purpose of providing quality healthcare. We require you to provide us with your personal details and a full medical history so that we mayproperly assess, diagnose, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways:

1. Administrative purposes in running our medical practice.
2. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
3. Disclosure to others involved in your health care, including treating doctors and specialists outside thismedical practice. This may occur through referral to other doctors, or for medical tests and in thereports or results returned to us following the referrals.

I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information.

I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me.

I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.

I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.

I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.

YesNo

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(Parent / Guardian if under 18 years)

RELEASING YOUR INFORMATION TO OTHER RELATIVES / FRIENDS

I give consent for Dr Hsu / Dr Singh's practice to release details regarding my treatment and/or condition to other members of my family *

YesNo

Please list the names of people who may receive information

Name

Relationship to patient

Name

Relationship to patient

Name

Relationship to patient

NSW Spine Specialists | 1300 975 800 | www.nswspinespecialists.com.au