Patient Form - Petterwood Orthopaedics

New patient registration form

Personal Information
Title*
First Name*
Last Name*
Address*
Street Address City State Post code
Home Phone
Work Phone
Mobile Phone*
Email*
Date of Birth*
Date Format: DD slash MM slash YYYY
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 Phone No.
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
Date Format: DD slash MM slash YYYY
Employer
Address
Email Address
Work Phone
Mobile Phone
Insurance Company
Address
Case Manager
Work Phone
Email Address
Fees
All consultations are payable at the time of service. The cost of consultation is above the Medicare schedule fee. This means you will not recover the full fee after claiming from Medicare. If you require further information about the payment of your consultation please feel free to speak to our friendly staff who will be happy to assist.

We accept cash, eftpos, and credit card (Mastercard and Visa only)

*Fees for Workcover claims require written consent by your employer and insurer prior to your consultation. If these fees are not paid by the insurer or employer the account becomes the responsibility of the patient.
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:
1. Administrative purposes in running our medical practice.
2. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
3. 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.
Patient Agreement*
- I agree to the terms and conditions

First Name	Last Name	Date of Birth

Name	Address	Phone

New patient registration form

New patient registration form

Personal Information

Medicare and Insurance

Referring Doctor

Other information

Fees

Consent to collect patient information