New Patient Information Form

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PATIENT INFORMATION
Name: _____________________________________________________ DOB______________________
Address: ______________________________________________________________________________
________________________________________________________________ Postcode _____________
(H): ________________________
(M): __________________________ (W): ______________________
GP Details: ____________________________________________________________________________
BILLING
Health Fund Name _____________________________________ Membership No: ___________________
Medicare Care No: _____________________________________ Patient Ref No _____ Expiry _________
Pension Card Holder YES / NO
CRN _____________________________________ Expiry _________
IS THIS PROBLEM RELATED TO:
Work Cover
YES / NO
Please circle appropriate answer
Employer Details : ______________________________
______________________________
Third Party
YES / NO
Legal Proceedings Pending
YES / NO
Have you consulted a Solicitor
YES / NO
If yes, Claim no ______________________________ Case Manager’s name _______________________
PERSONAL DETAILS
RIGHT OR LEFT HANDED:
RIGHT
LEFT
Occupation _____________________________ Main Duties ____________________________________
How did injury/complaint occur __________________________________________________________
PAST MEDICAL HISTORY
Diabetes
Y/N
Asthma
Y/N
Heart Disease
Y/N
Blood Pressure
Y/N
Epilepsy
Y/N
PAST SURGERY
Procedure
Year
Any other illnesses _______________________________________________________________________
Known Allergies: ________________________________________________________________________
Regular medications______________________________________________________________________
Do you smoke? Y / N How many / day________________________________
Do you drink Alcohol?
Y / N
If yes, how many standard drinks in 24hr period? ___________________
Regular Sports /Hobbies? _________________________________________________________________
PRIVACY POLICY AND CONSENT TO
RELEASE OF MEDICAL INFORMATION
The provision of quality health care requires a doctor-patient relationship of trust and
confidentiality. Consistent with our commitment to quality care, this practice had developed a policy
to protect privacy in compliance with the privacy legislation.
It is necessary for us to collect personal information from patients and sometimes others
associated with their health care in order to attend to their health needs and for administrative
purposes.
In the interests of the highest quality and continuity of the patient’s health care, this may also
include sharing information from other health care provides who comprise a patient’s medical team
from time to time.
This practice will also send a letter to all relevant health care providers including the referring
medical practitioner detailing the treatment provided.
I have read the above information and give my consent.
Name of Patient
_____________________________________
Signature
_____________________________________
(Patient, Parent or Guardian)
Date _____________
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