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?

Do you take weight loss or diabetic medication? (eg. Ozempic, Metformin, Saxenda)

Do you smoke?

NoSmokeVape

If yes, how many per day?

Alcohol consumption - How many drinks do you have per week?

*Smoking increases the risk of complications after foot and ankle surgery, including poor healing and, in severe cases, amputation. This may impact your suitability for surgery. Alcohol use can delay healing, and if surgery proceeds, you will be advised to stop alcohol intake during recovery.

Occupation:

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)

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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)

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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).

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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?

No Private Health Insurance Hospital Cover onlyExtras Cover onlyHospital and Extras Cover

If yes, which Health Fund are you insured with?

Please enter your membership number

Health Fund Reference No. (number next to name on card)

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.

Insurer name and/or Employer contact details (If Workers Comp claim) - Name, Address and Contact Phone Number

Date of Injury

Case Manager contact details

Please upload approval letter for your consultation from your Insurer/Employer

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Please upload any other relevant information for your appointment

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PRIVACY POLICY AND COLLECTION AND RELEASE OF MEDICAL INFORMATION

Collection of Personal Information

We collect personal information necessary for providing you with high-quality medical care and for managing our medical practice. This may include personal and contact details, medical and health information, credit card or direct debit details.

Your information may be stored securely in our electronic records system and/or in handwritten records.

Wherever possible, we will collect information directly from you. However, we may also obtain it from other sources such as hospitals, specialists, radiologists, and pathologists. Information may be collected by both medical and non-medical staff in person, over the phone, or in writing.

We take reasonable steps to ensure that the information we hold is accurate, complete, and up to date. Please notify us if your details change or you believe any information is incorrect.

Use of Voice Recognition Software in Consultations

To ensure accurate documentation of your consultation and prompt communication with your General Practitioner, our practice uses voice recognition/AI software. We use Dragon and Heidi, which comply with Australian privacy laws for use in medical practices.

By attending your consultation, you provide implied consent for the use of these programs. If you have any concerns, please contact us prior to your appointment.

Use and Disclosure of Personal Information

We treat your personal information as private and confidential. It will only be used or disclosed for purposes directly related to your care and treatment—such as sharing results with your GP or other healthcare professionals involved in your care.

Sharing of Medical Information

By attending this practice, you consent to the sharing of relevant information between Dr Amy Touzell’s practice (South East Orthopaedics) and other members of your healthcare team. This includes, but not limited to, your general practitioner, other treating doctors or specialists, hospitals, radiology and pathology providers. This may involved the exchange of results and correspondence, both written and verbal.

Billing

Payment is due at the time of consultation.
Out-of-pocket surgical fees are payable at the first post-operative visit.
You are fully liable for any fees resulting from rejected WorkCover, TAC, or private health fund claims, where applicable.
Accounts overdue by more than 90 days may be referred to a collection agency or legal firm, and you will be responsible for any additional costs incurred, including administrative or legal fees.

Patient Acknowledgement and Consent

Please sign below to confirm that you have read, understood, and consent to the above terms regarding your care, privacy, and billing at South East Orthopaedics

Please sign here

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