New Patient Registration Form - Mr Ilan Freedman

Patient Information

Name*

Clinical Problem*

E.g. Sore hip or knee Arthritis

Address*

Street Address City State Postcode

Email*

Phone (Home)

Phone (Work)

Phone (Mobile)

Next of Kin Details

Name*

Relationship*

Phone Number*

Referring Healthcare Practitioner

Name*

Address*

Street Address City State Postcode

Telephone*

Fax

GP Details

GP Type*

Same as referrer

Name*

Address*

Street Address City State Postcode

Telephone*

Fax

Account Details

Medicare Number*

Private Health Insurance*

Yes
No

Fund Name*

Membership Number*

Dept. Veterans Affairs Card Number:

Card Type

White
Gold

Expiry Date

Claim Details

Is this covered by WorkCover?*

Yes
No

Date of Injury

DD

MM

YYYY

Claim Number

Employer

Employer's Address

Street Address City State Postcode

Telephone

Insurance Company

Insurance Company Address

Street Address City State Postcode

Case Manager

Telephone

Fax

Medical History

Other Practitioners Involved in your care

Other Medical Problems/History

Are You Diabetic?*

Yes
No

Diabetic Medication?*

Please state what diabetic medication you take?

Do you have drug allergies?*

Yes
No

Please include details*

Do You Take Plavix/Warfarin, Blood Thinners?*

Yes
No

Please include details*

Do You Have A Pacemaker or Stent?*

Yes
No

Cardiologist

Due to Privacy Legislation, we require your consent to collect personal information. This practice collects your information in order to identify your medical record and provide an accurate, quality health service. This means we will use the information you provide in the following ways:

Administrative purposes in running a specialist medical practice; including pre-operative and post-operative calls using phone numbers and names you have provided to us, as well as hospital interaction for booking surgical or delivery services
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements • Disclosure to others involved in your medical care, including treating doctors, specialists, hospital booking staff outside this practice.
This may occur through referral to other doctors, surgery at hospitals, for medical tests and in the reports or results returned to us following the referrals.

I have read the information above and understood the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information. 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 health care and treatment provided to me. I am aware of my right to access the information collected about me, except in circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances. I understand that if my information is used for any other purpose other than set out above, my further consent will be obtained. I consent to the handling of my information by this practice for the purpose set out above, subject to any limitations on access or disclosure and I notify this practice by submitting this form.

Comments

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