Patient Registration Form

Thank-you for registering online with South East Orthopaedic Surgery. Please answer all the questions below. If you do not already have an appointment scheduled please contact our rooms on 8751 8466 to book an appointment. Completion of this form does not automatically generate an appointment.

Title

First Name

Last Name

Preferred name

Date of birth

Mobile number:

Home phone number:

Email Address

Home address

Surburb / Postcode

Postal address (If different from your home address)

Do you have any allergies? If yes, please enter details.

Do you have any medical conditions that may affect your surgery? (eg diabetes, heart conditions, asthma etc)

Do you take ANY blood thinners such as (but not limited to): aspirin, warfarin, pradaxa, xaralto, plavix or dabigatran?

Who should we contact in an emergency?

What is their best contact number?

What is their relationship to you?

Who is your referring doctor? Please enter their name and practice details.

Please upload your referral letter (alternatively this can be faxed to us on (03) 9978 9461 or brought to your appointment)

Browse

Is your referring doctor your usual general practitioner?

YesNoI don't have a regular general practitioner

If no, please enter your regular general practitioner's details

Please enter the details of other health practitioners involved in your care (eg physiotherapist, podiatrist, osteopath etc)

Please upload any correspondence you may have from your other health practitioner (eg physiotherapist letter)

Browse

Have you had any imaging such as an x-ray, MRI scan, ultrasound scan etc?

Where were these done? (If you are not sure, please leave blank).

Please upload any test results you may have (if you do not have access to them, please leave blank).

Browse

Medicare Card Number

Medicare card expiry date

Patient's Medicare Reference No. (number next to name on card)

If patient is under 15 years old - Parent's name, DOB & Medicare Reference No.

Do you have private health insurance?

YesNo

If yes, please select your health fund

Please enter your membership number

Are you a pensioner or concession card holder?

If yes, please enter your pension or HCC number

Department of Veteran's Affairs No. (if applicable)

DVA Card Colour (if White Card please specify area covered)

Is your appointment regarding a Workers' Compensation or TAC claim?

Claim No.

Date of Injury

Case Manager contact details

Insurer name and/or Employer contact details (If Workers Comp claim)

PRIVACY POLICY AND COLLECTION AND RELEASE OF MEDICAL INFORMATION

A full copy of our Privacy Policy is available on our website www.southeastortho.com.au or at our Practice.

Collection of personal information

We collect information that is necessary and relevant to provide you with medical care and treatment, and manage our medical practice. This information may include personal details, health information, credit card/direct debit details and contact details. This information may be stored on our computer medical records system and/or in hand written medical records. Wherever practicable we will only collect information from you personally, however occasionally we may collect information from other sources such as other health care providers, radiologists, pathologists, hospitals. Information may be collected by medical or non-medical staff of our practice, in person, via email, text message, over the phone or in writing.

We will take reasonable steps to ensure that your personal information is accurate, complete, up to date and relevant. We request that you let us know if any of the information we hold about you is incorrect or out of date.

Use and Disclosure

We will treat your personal information as strictly private and confidential. We will only use or disclose it for purposes directly related to your ongoing care and treatment eg. The disclosure of information/results to your GP or other members of your health care team.

Sharing of medical information

I agree to the sharing of relevant information between Dr Amy Touzell’s practice (South East Orthopaedics) and other members of my healthcare team, including but not limited to, my General Practitioner, other treating Doctors/Specialists, allied health, Hospitals, Radiology and Pathology providers. This includes, but is not limited to, correspondence between members of my healthcare team (and their practices) and collection and sharing of results. Results may be shared via email, fax, phone call or hard copy letter.

Billing

• Payment is expected at the time of consultation. Out of pocket fees for surgery are payable at the first postoperative visit.

• The patient will accept full liability for rejected Work cover, TAC and health fund claims where applicable.

• In the unlikely event your account is overdue for more than 90 days, you may be referred to a collection agency and/or law firm. You will be liable for all costs which may be incurred, including additional legal demand/administration costs.

I have read and understood the billing arrangements.

Please sign here to confirm you agree to our privacy and billing policies.

Draw signature|Type signatureClear

Today's date