New Patient Form Appointment cancellations after 9am the working day prior to your appointment (2 Business days for Psychology appointments) may incur a 50% cancellation fee.* indicates required fields Patient DetailsName* MrMrs.MissMs.Dr.Prof.Rev.Other Prefix First Middle Last If you selected 'Other' please fill out below Date of Birth* DD slash MM slash YYYY Home Address* Street Address Suburb/Town State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta 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FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Postal Address As Above Postal Address* Street Address Suburb/Town State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Country of birth AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Select any that apply Aboriginal Torres Strait Islander Home PhoneMobile PhoneOccupation Work PhoneNext of Kin* First Name Last Name Next of Kin Phone*Referring Doctor First Name Last Name Regular Doctor First Name Last Name Patient Weight (kg)*Please enter a number from 0 to 200.Patient Height (cm)*Please enter a number from 0 to 250.Are you responsible for payment of this account?* Yes No Who is reponsible for payment?*SelectParent/GuardianWorkCoverTACParent/Guardian Name* Date of accident* DD slash MM slash YYYY Location and injury diagnosis* eg: Ankle/Knee/Shoulder – Fracture/Sprain/DislocationInjury side* Right Left Both Have you lodged a claim* Yes No Claim Number (if known) Employer Name* Contact Name* Contact Phone*Name of Insurance company (if known) Address* Street Address Suburb State Post Code Medical HistoryAre you seeing any other Specialist or Physician?* Yes No Who is the Specialist or Physician?* Are you seeing a Physiotherapist?* Yes No Who is the Physiotherapist?* Have you had radiology imaging done?* Yes No Which Provider did you use?* Do you have any allergies?* Yes No Please specify* Are you a Diabetic?* Yes No Are you Insulin Dependent?* Yes No Are you currently taking any of the following medications (tick all that apply) Warfarin Aspirin Clopidogrel – Plavix Prednisolone Xarelto Methotrexate Any Anti-Inflammatories? (please specify) Health CareMedicare Card Number* Reference Number (Left of patient name)* Expiry (MM/YYYY)* Is the patient under 16 years of age* Yes No Parent/Guardian Date of Birth* DD slash MM slash YYYY Parent/Guardian Medicare Card Number* Parent/Guardian Reference Number (Left of patient name)* Parent/Guardian Medicare Card Expiry (MM/YYYY)* Private Health Fund?* Yes No Covered for* Private Hospital Public Hospital only Extras Covered for more than 12 Months* Yes No Name of Fund* Membership Number* Veteran's Affairs* Yes No Card Number* Privacy StatementPrivacy Consent* I have read the Privacy Statement and consent to the conditions.BallaratOSM Pty Ltd, their partners and staff are committed to the protection of your privacy. We require you to provide your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. This means that we will use the information you provide in the following ways: > Administrative purposes in running our medical practice. > Billing purposes, including compliance with Medicare and Health Insurance Commission requirements. > Disclosure to others involved in your health care, through treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following referrals. > Disclosure for research and quality assurance activities to improve individual and community health care and practice management. (Individuals are not identified in these circumstances.) > X-rays and de-identified clinical photographs may be used for teaching purposes. ********************************* I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on the handling of 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 the health care and treatment given to me. I understand that if my information is to be used for any other purpose other than that set out above, my further consent will be obtained. 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 that I notify this practice of.Subscribe to our newsletters* Ballarat OSM newsletter Ballarat Sports Medicine Newsletter I do not want to be subscribed Important Account InformationConsultation costs must be paid on the day. Costs incurred in relation to the fitting of a Vacoped boot or Vacocast, additional liner or even up are payable on the day. Reimbursement may be sought from your Health Insurance provider (through your extras cover), Department of Veterans Affairs, Employer, Workcover Insurer or the TAC Extra costs for surgery must be paid prior to the date of surgery. Any account that remains unpaid for a period of 90 days will result in the denial of any future appointment being made within the practice. Any costs involved in recovering outstanding accounts will be the responsibility of the patient. QuestionnaireWe at BallaratOSM Pty Ltd are always aiming to improve our services we provide to you. To help us could you please fill in the brief question below.Why did you chose Ballarat Orthopaedics and Sports Medicine? (tick any that apply) GP Recommended Sports Physician Recommended Physiotherapist Recommended Family/Friend Recommended Hospital/Emergency Department AFL Goldfields Website Google Brochure/Poster/Advertising Other Please Specify* CommentsThis field is for validation purposes and should be left unchanged.