EXAMPLE - New Patient Form

Dr Brian Hsu MBBS MMed FRACS (Orth) FAOrthA FHKAM
Adult and Paediatric Spine Surgeon

Dr Bhisham Singh MBBS MS FRCS (Eng) FRACS
Orthopaedic and Spine Surgeon
PATIENT REGISTRATION FORM
Title
Family Name*
First Name
Middle Name(s)
Full Name of Parent, in the case of minors
Street Address*
Suburb*
State*
Postcode*
Email
Mobile*
Telephone
Work Phone
Sex*
Age
Date of Birth*

DayMonthYear
Occupation
NEXT OF KIN
Name
Relationship
Mobile
Telephone
Fax
Private Health Insurance*

YesNo
Health Fund Name
Health Fund Name
Health Fund Member Number
Aged Care Pensioner

YesNo
Pension Number
Expiry Date

DayMonthYear
Medicare Number
Position on Card
Veterans Affairs Care No
Referring Dr’s Name
Referring Dr’s Address
Suburb
State
Postcode
General Practitioner’s Name
General Practitioner’s Address
Suburb
State
Postcode
General Practitioner’s Telephone
Is this a Workers Compensation Claim?*

YesNo

PATIENT REGISTRATION FORM
WORKERS COMPENSATION CLAIM
(for workers comp claims only)
Employer*
Date of Injury*

DayMonthYear
Date
Employer’s Address
Suburb
State
Postcode
Solicitor's Name (if applicable)
Solicitor’s Address
Suburb
State
Postcode
Insurance Company Name
Insurance Company Name*
Insurance Company Address
Suburb
State
Postcode
Case Manager First Name*
Last Name
Case Manager Telephone*
Fax

PATIENT REGISTRATION FORM
CONSENT FORM

We require your consent to collect personal information about you. Please read this information carefully, and sign where indicated below.

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with 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 we will use the information you provide in the following ways:
1. Administrative purposes in running our medical practice.
2. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
3. Disclosure to others involved in your health care, including 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 the referrals.
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 handling 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 am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.

I understand that if my information is to be used for any other purpose other than 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 of which I may notify this practice.
Patient Name
Parent/Guardian, if under 18 years
Signed*

Clear
Parent/Guardian, if under 18 years
Date

DayMonthYear
Releasing Your Information to other Relatives/Friends

I give consent for Dr Brian Hsu's / Dr Bhisham Singh's practice to release details regarding my treatment and/or condition to other members of my family.
Please specify if you give consent to releasing details of treatment.

YesNo

Please list the names of people who may receive information.

	Name	Relationship to patient
1.
2.
3.

Office Use Only
Date:	_______________
Weight:	_______________
Height:	_______________
B/P:	_______________
HR:	_______________
Temp:	_______________

Should be Empty:

	Yes	No
Neck pain
Shoulder pain
Arm pain
Upper back pain
Low back pain
Hip/Leg pain

	Tick if you have had this	BETTER	WORSE	NO CHANGE
Bed Rest
Pool Therapy
Physiotherapy
Traction
Medication
Acupuncture
Chiropractic Adjustment
TENS/Electrical Stim
Hot packs
Ice packs
Ultrasound
Massage
Yoga/Tai-Chi
Braces/Splints
Biofeedback
Spine Injections

	Year	Operation	Place Hospitalised

	Name of Medicine/Substance	Type of Reaction	Date (if known)

CONSENT FORM