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: Please circle appropriate answer

Work Cover YES / NO 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 PAST SURGERY

Procedure Year

Diabetes

Asthma

Y/N

Y/N

Heart Disease

Blood Pressure

Y/N

Y/N

Epilepsy Y/N

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 ca re 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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