Patient Registration Form

PERSONAL DETAILS

TITLE *

FIRST NAME *

SURNAME *

DATE OF BIRTH *

MOBILE PHONE *

HOME PHONE

EMAIL ADDRESS *

ADDRESS *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

MEDICARE NO. *

REF NO. *

EXP DATE *

VETERANS AFFAIRS NO. (If applicable)

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INSURANCE DETAILS | WORKCOVER | TAC

DO YOU HAVE PRIVATE HEALTH INSURANCE *

Yes
No

IF YES DO YOU HAVE HOSPITAL COVER

Yes
No

HEALTH INSURANCE FUND NAME

If applicable

FUND MEMBERSHIP NUMBER

If applicable

ARE YOU CLAIMING THROUGH WORKCOVER *

Yes
No

WORKCOVER CLAIM NO.

EMPLOYER NAME

WORKCOVER INSURANCE COMPANY

(eg. Allianz, EML)

CASE MANAGER NAME

Full name

CASE MANAGER PHONE NO.

CASE MANAGER EMAIL

If known

ARE YOU COMING THROUGH TAC *

Yes
No

TAC CLAIM NO.

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IF PATIENT UNDER 14 YEARS - PARENT/GUARDIAN DETAILS

PARENT/GUARDIAN FIRST NAME

PARENT/GUARDIAN SURNAME

REALTIONSHIP TO PATIENT

MOBILE PHONE

HOME PHONE

EMAIL

DATE OF BIRTH

PARENT/GUARDIAN MEDICARE NO.

REF NO.

EXP DATE

REFERRING DOCTOR

CLINIC/HOSPITAL

IS THE REFERRING DOCTOR YOUR USUAL GP

Yes
No

IF NO, PLEASE ENTER YOUR USUAL DOCTOR'S NAME

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INJURY/CONDITION DETAILS & IMAGING

LOCATION OF INJURY/FOOT/ANKLE CONDITION *

IMAGING OF INJURY - Have you had imaging taken: *

IMAGING PROVIDER - If applicable *

Please tick "Not applicable" box if this does not apply.

IF OTHER - Please indicate:

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PATIENT HEALTH QUESTIONS

PLEASE INDICATE IF ANY OF THE FOLLOWING APPLY:

Smoker
Diabetic
Take blood thinners
Medicine allergies

IF MEDICINE ALLERGIES - Please specify

HAVE YOU PREVIOUSLY HAD ANY OF THE FOLLOWING

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PRIVACY, FEES & CONSENT

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 NAME *

SURNAME *

TODAY'S DATE *

HOW DID YOU HEAR ABOUT MR KEITH

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PLEASE ATTACH ANY RELEVANT FILES - REFERRAL LETTER OR IMAGING UP TO 10MB

Click or drag files to this area to upload. You can upload up to 5 files.

Up to 5 files can be added for under a total of 10MB

Mr Troy Keith
MBBS (Hons), FRACS (Orth), FAOrthA.
Orthopaedic Foot & Ankle and Trauma Surgeon

CALL US (03) 9509 7794

ALL NEW PATIENTS