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 Details

Name*

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 Country

Postal Address

As Above

Postal Address*

Street Address Suburb/Town State Post Code Country

Email*

Home Phone

Mobile Phone

Occupation

Work Phone

Next of Kin*

First Name Last Name

Next of Kin Phone*

Next of Kin Relationship*

Usual GP and clinic (NA if not applicable)*

Name Clinic

Patient Weight (kg)*

Please enter a number from 0 to 200.

Patient Height (cm)*

Please enter a number from 0 to 250.

Are you a minor under 16 or claiming through WorkCover/TAC?*

Yes

Please select most appropriate*

Parent/Guardian Name*

WorkCover & TAC patients are responsible for payment of accounts

Date of accident*

DD slash MM slash YYYY

Location and injury diagnosis*

eg: Ankle/Knee/Shoulder – Fracture/Sprain/Dislocation

Injury side*

Right

Left

Both

Have you lodged a claim*

Yes

Claim Number (if known)

Employer Name*

Contact Name*

Contact Phone*

Employer WorkCover Agent/Insurer (If known)

Address*

Street Address Suburb State Post Code

Medical History

Are you seeing any other Practitioner?*

Yes

Who is the Specialist or Physician?*

Do you have a usual physiotherapist?*

Yes

Who is your physiotherapist/clinic?*

Have you had radiology imaging done?*

Yes

Which Provider did you use?*

Health Care

Medicare Card Number*

Reference Number (Left of patient name)*

Expiry (MM/YYYY)*

Is the patient under 16 years of age*

Yes

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

Covered for*

Hospital

Extras

Hospital cover level

Gold

Silver Plus

Silver

Bronze

Covered for more than 12 Months*

Yes

Name of Fund*

Membership Number*

Veteran's Affairs*

Yes

Pension/Health Care Card holder?

Yes

Card Number*

Privacy Statement

Privacy 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.

Important Account Information

Consultation/Procedure costs must be paid on the day (This includes WorkCover and TAC patients).

Payment is by EFTPOS or cheque. Cash is NOT accepted.

Failure to pay on the day will result in an additional administration fee being charged.

Costs incurred for additional equipment or medical aids are payable on the day.

Reimbursement may be sought from your Health Insurance provider (extras cover), Department of Veterans Affairs, Employer, Workcover Insurer or the TAC.

Out of pocket costs for surgery must be paid 2 weeks prior to the date of surgery.

Any unpaid invoice may result in the denial of any future appointment within the practice.

Any costs involved in recovering unpaid invoices will be the responsibility of the patient.

Questionnaire

We 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*

Phone

This field is for validation purposes and should be left unchanged.

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 Details

Name*

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 Country

Postal Address

As Above

Postal Address*

Street Address Suburb/Town State Post Code Country

Email*

Home Phone

Mobile Phone

Occupation

Work Phone

Next of Kin*

First Name Last Name

Next of Kin Phone*

Next of Kin Relationship*

Usual GP and clinic (NA if not applicable)*

Name Clinic

Patient Weight (kg)*

Please enter a number from 0 to 200.

Patient Height (cm)*

Please enter a number from 0 to 250.

Are you a minor under 16 or claiming through WorkCover/TAC?*

Yes

Please select most appropriate*

Parent/Guardian Name*

WorkCover & TAC patients are responsible for payment of accounts

Date of accident*

DD slash MM slash YYYY

Location and injury diagnosis*

eg: Ankle/Knee/Shoulder – Fracture/Sprain/Dislocation

Injury side*

Right

Left

Both

Have you lodged a claim*

Yes

Claim Number (if known)

Employer Name*

Contact Name*

Contact Phone*

Employer WorkCover Agent/Insurer (If known)

Address*

Street Address Suburb State Post Code

Medical History

Are you seeing any other Practitioner?*

Yes

Who is the Specialist or Physician?*

Do you have a usual physiotherapist?*

Yes

Who is your physiotherapist/clinic?*

Have you had radiology imaging done?*

Yes

Which Provider did you use?*

Health Care

Medicare Card Number*

Reference Number (Left of patient name)*

Expiry (MM/YYYY)*

Is the patient under 16 years of age*

Yes

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

Covered for*

Hospital

Extras

Hospital cover level

Gold

Silver Plus

Silver

Bronze

Covered for more than 12 Months*

Yes

Name of Fund*

Membership Number*

Veteran's Affairs*

Yes

Pension/Health Care Card holder?

Yes

Card Number*

Privacy Statement

Privacy Consent*

I have read the Privacy Statement and consent to the conditions.

Important Account Information

Questionnaire

We 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*

This field is for validation purposes and should be left unchanged.

Patient Details

Medical History

Health Care

Privacy Statement

Important Account Information

Questionnaire

Patient Details

Medical History

Health Care

Privacy Statement

Important Account Information

Questionnaire

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