Confidential Patient Registration Form

Patient Registration Form

Please complete the information and we will get in touch with you shortly.

Step 1 of 3 - Confidential Patient Registration Form

Title
Last Name:*
First Name:*
Date of Birth:*
Email:*
Address:*
Suburb:*
Post Code:*
Best Phone Number:*
Occupation:
Parent/Guardian Name: (if under 18 years)
Medicare Number
Ref:
Valid to:
DVA Number:
DVA Class:
Health Fund:
Membership No:
Referring Doctor:
Tel:
Address:
Family Doctor (if different):
Tel:
Address:
Area(s) for Treatment (eg left wrist, right ring finger):
Is this for a workers compensation or motor vehicle accident claim?*
- Yes
- No

Please read and sign
Payment is required at the end of each consultation. In the unlikely event that the payment is overdue by more than 90 days, you will referred to a debt recovery agency, and be responsible for the associated costs for recovering this debt (usually an additional 20%).
This practice is a private sector health provider. It is bound by the National Privacy Act and the Health Records and Information Privacy Act. These principles set the standards by which personal information is collected from patients.
As part of your treatment, it is usual to write to:
- Your referring doctor,
- Your family doctor,
- The physiotherapist or hand therapist involved in your care, and
- Any specialist to whom you are referred (including for x-rays, scans or pathology tests).
In the case of compensation matters, it may be necessary to write to:
- The insurer,
- The solicitor,
- Your employer, and
- The Rehabilitation provider/consultant.
Only necessary information will be released.
You are likely to have digitised x-rays and/or clinical photographs taken as part of your management. They are useful in discussing the diagnosis and treatment with you and other clinicians. They can also be very useful for teaching purposes and research.
All images used for these purposes will be de-identified.
Hidden
Terms and Conditions
Payment is required at the end of each consultation. In the unlikely event that the payment is overdue by more than 90 days, you will referred to a debt recovery agency, and be responsible for the associated costs for recovering this debt (usually an additional 20%). This practice is a private sector health provider. It is bound by the National Privacy Act and the Health Records and Information Privacy Act. These principles set the standards by which personal information is collected from patients. As part of your treatment, it is usual to write to:</p> - Your referring doctor, - Your family doctor, - The physiotherapist or hand therapist involved in your care, and - Any specialist to whom you are referred (including for x-rays, scans or pathology tests). In the case of compensation matters, it may be necessary to write to: - The insurer, - The solicitor, - Your employer, and - The Rehabilitation provider/consultant. Only necessary information will be released. You are likely to have digitised x-rays and/or clinical photographs taken as part of your management. They are useful in discussing the diagnosis and treatment with you and other clinicians. They can also be very useful for teaching purposes and research. All images used for these purposes will be de-identified.
Do you consent to x-rays or photographs to being used for teaching purposes.*
- Yes
- No
Tick if youdo notconsent to x-rays or photographsto beingused for teaching purposes.
- Tick if you do not consent to x-rays or photographs to be used for teaching purposes.
Signature

Dr Simon Chan

Dr Simon Chan

Confidential Patient Registration Form

Patient Registration Form

Step 1 of 3 - Confidential Patient Registration Form

To be completed for WorkCover or Third Party Claims

Please read and sign

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