TBOFC Registration

PATIENT DETAILS

First Name *

Surname *

Preferred Name

Date of Birth *

Age in Years

Email *

Address *

Mobile

Phone

Please enter at least one phone number

Medicare Number *

Ref No *Number next to your name

Exp Date *

Parent's Medicare Number *

Parent Ref No *

Parent DOB *

These details are needed to submit a Medicare claim for patients under 18.

Private Health Fund

Number

WorkCover Claim No

Case Manager

DVA No

Colour

GoldWhite

Next of Kin *

Phone *

GP *Full Name and Practice Address

Allergies *

Weight (kg) *

Height (cm) *

BMI

Occupation *

MEDICAL INFORMATION

Do you have a history of heart disease? *

YesNo

Do you have a history of high blood pressure? *

YesNo

Are you diabetic? *

YesNo

Do you take Asprin or blood thinning medications, for example Warfarin, Plavix or Fish Oil? *

YesNo

Do you have a history of blood clots? *

YesNo

Do you have a history of hepatitis or HIV? *

YesNo

Medications *Please include dose and timing

SURGEON'S FEES EXPLAINED

Fees for surgical procedures performed by surgeons at The Bay Orthopaedic & Fracture Clinic will be discussed with you and will be in line with the Australian Medical Association’s (AMA) recommendations. Medicare and Private Health Insurance does not cover the full cost of surgical fees. The front desk staff will be happy to provide you with a quote for your surgery, which will clarify your out-of-pocket expenses.

CONSENT
I consent to the collection and disclosure of information to/from Medical/Specialist Practitioners, Allied Health Practitionersand institutions that may require information about my medical history, but only to the extent necessary to access/treat theparticular condition that I have consulted the Specialist Practitioner about. I understand I can retract this consent at any timeand to do this, must so in writing. I understand that I will be responsible for and agree to pay all The Bay Orthopaedic &Fracture Clinics accounts and will indemnify and keep indemnified The Bay Orthopaedic & Fracture Clinic from all costs,commissions, fees, charges and expenses including, but not limited to, solicitors costs and debt collection charges incurredby The Bay Orthopaedic & Fracture Clinic in the recovery of any overdue monies. Other fees may be incurred for plastercasts, moon boots, injections, splints, etc.

I agree

I have read and understood the above terms. I agree that payment of the account in full is MY responsibility.

Signature *

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Date