Patient Form - Petterwood Orthopaedics

Personal Information

Title*

First Name*

Last Name*

Address*

Street Address City State Post code

Home Phone

Work Phone

Mobile Phone*

Email*

Date of Birth*

Next of Kin*

Next of Kin Contact No.*

Next of Kin Relationship to Patient*

Medicare and Insurance

Medicare No.*

Reference Number on card*

Private Health Fund

Membership No.

Is the patient under 18 years of age?*

Yes
No

Person responsible for the account:*

First Name	Last Name	Date of Birth

Medicare No.*

Reference Number on card*

Do you have a DVA card?*

Yes
No

DVA Card Number

Referring Doctor

Referring Doctor*

Type*

If your referring Doctor is not your usual GP, please fill out details below.

Usual GP

Usual GP Clinic

Notify Other Medical Practitioners?

Are there other medical practitioners you would like correspondence to be sent to apart from your referring doctor and usual GP?

Name	Address	Phone

Other information

Is this a Workcover claim?

Yes

Is this a MAIB claim?

Yes

Claim number / MAIB number

Date of Injury

Employer

Address

Email Address

Work Phone

Mobile Phone

Insurance Company

Address

Case Manager

Work Phone

Email Address

How did you hear about us?

Please specify

Fees

Petterwood Orthopaedics collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in the following ways:

Administrative purposes in running our medical practice.
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you.

• I understand the reasons why my information must be collected.
• 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 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.
A third party directly involved in the development and management of your healthcare plan.

Consent to collect patient information

Petterwood Orthopaedics collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in the following ways:

Administrative purposes in running our medical practice.
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you.

• I understand the reasons why my information must be collected.
• 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 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.
A third party directly involved in the development and management of your healthcare plan.

Patient Agreement*

I agree to the terms and conditions

New patient registration form

New patient registration form

Personal Information

Medicare and Insurance

Referring Doctor

Other information

How did you hear about us?

Fees

Consent to collect patient information