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 belowDate 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* Home PhoneMobile PhoneOccupationWork PhoneNext of Kin* First Name Last Name Next of Kin Phone*Next of Kin Relationship*Usual GP 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 responsible for payment of this account?* Yes No Who is reponsible for payment?*SelectParent/GuardianWorkCoverTACParent/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/DislocationInjury side* Right Left Both Have you lodged a claim* Yes No Claim Number (if known)Employer Name*Contact Name*Contact Phone*Employer WorkCover Agent/Insurer (If known)Address* Street Address Suburb State Post Code Medical HistoryAre you seeing any other Practitioner?* Yes No Who is the Specialist or Physician?*Have you had radiology imaging done?* Yes No Which Provider did you use?*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* Hospital Extras Hospital cover level Gold Silver Plus Silver Bronze Covered for more than 12 Months* Yes No Name of Fund*Membership Number*Veteran's Affairs* Yes No Pension/Health Care Card holder? 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.Important Account InformationConsultation/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. 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.
