Patient Registration Form

Title

Surname *

First Name/s *

Preferred Name

Date of Birth *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Home Tel.

Work Tel.

Mobile *

Email

Do you want to receive SMS or Email messages for appointment reminders?

Yes
No

Occupation

Part of Body Injured

Do you have Medicare? *

Yes
No

Next of Kin

Relationship

Mobile

Home

Do you have private health insurance? *

Yes
No

Are you a member of Veterans' Affairs?

Yes
No

Do you have an Aged Pension Card?

Yes
No

Referring Doctor

Clinic Name

Address

Local Doctor

Clinic Name

Address

Other Doctors

Name

Address

TAC

Transport Accident *

Yes
No

WorkCover

Work Cover *

Yes
No

Do you take Aspirin or Blood Thinners? If yes, please specify the medication names

Do you have a Pacemaker? If yes, please specify type of pacemaker and when inserted

Please list down previous surgeries, if any

please mention any allergies or other significant medical history

PRIVACY CONSENT

Spine & Orthopaedic Centre collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and full medical history so that we may properly assess, diagnose, treat and be proactive in your healthcare needs.

Please read this form carefully, and sign where indicated below

This means we will use the information you provide in the following ways:

Administrative purposes in running our practice.
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
Disclosure to others involved in your health care, including treating doctors, specialists and allied health practitioners outside this medical practice. This may occur through referral to other doctors, or for medical tests and in reports returned to us following the referral.
Disclosure to other doctors or allied health practitioners within the practice for the purpose of continuity of patient care.
For disclosure to visiting doctors and medical students attached to this practice for the purpose of patient care and teaching.
Disclosure for the purpose of research and quality assurance activities to improve individual and community health care and practice management. Usually no individual names will be recorded but if this is not the case, you will be informed when such activities are being conducted and given the opportunity to ‘opt out’ of any involvement.
For quality review and accreditation of the practice, medical records may need to be assessed by a visiting doctor.

I have read the information above and understand the reasons why my information must be collected. I am also aware that the Spine & Orthopaedic Centre has a privacy policy on handling patient information. 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 a reasonable explanation in these circumstances. I consent to the handling of my information by Spine & Orthopaedic Centre for the purposes set out above, subject to any limitations on access or disclosure that I notify in writing to Spine & Orthopaedic Centre. There are some circumstances where information needs to be disclosed without consent ie:

An emergency situation
Where disclosure is necessary to lessen or prevent a serious and imminent threat to an individual’s life, health or safety, or is a serious threat to public health or safety.
Where disclosure is a legal requirement, eg a communicable disease, suspected abuse, subpoena to court
For medical indemnity insurance

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 health care and treatment given to me.

I consent to Spine & Orthopaedic Centre taking my photograph (which will be kept on my computer file only) for the purposes of identification and improved patient care. I understand this photograph will not be released to any other party.

Yes
No

I give permission for the staff of Spine & Orthopaedic Centre to call my listed home and mobile phone numbers to relay information such as appointment times. If I am unable to take the call I also give permission for Spine & Orthopaedic Centre staff to leave a message with whoever answers the phone.

Yes
No

Signature *

Clear Signature

Date *

Your Name / Guardian *

Important Notice for New Patients

Disclaimer Form

(Must be completed by new patients)

If your appointment pertains to obtaining a medical report or to provide any other correspondences relating to the management of your condition to Workcover, TAC, Centrelink, NDIS etc, please note that Spine & Orthopaedic Centre DOES NOT provide this.

If you are requiring this, you must contact the rooms on 03 9796 2992 and discuss this with one of our staff members.

Please note that the default turnaround time for responses to emails and questions in relation to the above is between ten to twelve weeks. We appreciate your patience and understanding.

By signing below, you have read and understand the above notice and that you are being treated by Spine & Orthopaedic Centre as a private patient.

Signature *

Clear Signature

Date *

Your Name / Guardian *

Other Doctors

TAC

WorkCover

PRIVACY CONSENT

Important Notice for New Patients

Disclaimer Form

(Must be completed by new patients)

Request for an appointment

Spine & Orthopaedic Centre