ALL NEW PATIENTS

WELCOME TO ALL NEW PATIENTS – Please fill in the following online form to help Mr Keith and his team manage your medical care.

PATIENT REGISTRATION FORM

IMPORTANT – Please read the below form carefully and fill in the details and hit the submit button when complete. The form takes about 5 minutes to complete and will allow Mr Keith and his team to provide you with accurate and timely medical care.

PATIENT PREFERRED TITLE - (Mr, Miss, Mrs etc.) *

PATIENT NAME *

First

Last

PATIENT DATE OF BIRTH - eg DD/MM/YYYY: *

EMAIL *

PATIENT ADDRESS - Full address *

Street No. | Street Name | Suburb | City | Postcode

MOBILE PHONE NUMBER | HOME PHONE NUMBER *

Please supply mobile and home phone number if possible.

MEDICARE No. | DVA No. - If applicable

Medicare No. | Ref No. | Exp Date

DO YOU HAVE PRIVATE HEALTH INSURANCE - Fund Name (if applicable) *

i.e. Bupa - Please check for hospital cover or N/A for not applicable.

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PLEASE SUPPLY PRIVATE HEALTH INSURANCE FUND NUMBER - If applicable *

Fund Number | 0000 0000 - N/A if not applicable.

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IF CLAIMING THROUGH WORKCOVER - Please supply claim no.

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IF CLAIMING THROUGH TAC - Please supply claim no.

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IF PATIENT U/18 YEARS - PARENT/GUARDIAN NAME

First

Last

RELATIONSHIP TO PATIENT

MOBILE PHONE NUMBER | HOME PHONE NUMBER

Please supply mobile and home phone number if possible.

REFERRING DOCTOR NAME | CLINIC OR HOSPITAL

Please supply the referring specialists name and where they work.

IS THE REFERRING DOCTOR YOUR USUAL GP

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IF OTHER - Please indicate:

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PLEASE INDICATE IF ANY OF THE FOLLOWING APPLY:

Smoker
Diabetic
Take blood thinners
Medicine allergies

IF MEDICINE ALLERGIES - Please specify

PRIVACY POLICY - I understand that this practice handles personal information in accordance with the National Privacy Principles enshrined in the Privacy Act 1988 (Commonwealth) and as outlined in the Privacy Statement. I consent to the handling of my information by this practice, including via email, fax and postage, for the purpose of providing quality health care, associated administrative and billing purposes, and disclosure for research and quality assurance activities. We take reasonable steps to protect information and your privacy when transmitting your information. We will use post, secure messaging, facsimile, and email, to transmit your information, on request or as appropriate. You acknowledge that email is not a secure form of transmission. We are unable to provide clinical advice to patients via email. I also give permission for medical information to be obtained from any other source in order to help with my treatment. *

Yes - I confirm I have read and understand the above policy and give my consent.

FEES - Your consultation fee will be advised when making your appointment. If you are eligible for Medicare rebates, on receipt of your fee payment your claim will be submitted directly to Medicare. An additional fee may be charged for ultrasound guided injections provided in rooms by Mr Keith.

I am the legal guardian of a patient under the age of 18.

Consent *

Yes - I have read and understand the above fees policy.

I HAVE READ AND UNDERSTAND THE FEES & PRIVACY POLICY *

First

Last

TODAYS DATE - eg DD/MM/YYYY: *