New Patient Registration

Please complete this patient information form. Upon completion, you’ll be asked some basic questions about your current health.
You may also download this form at the bottom of this page.

Title

Name

First Name

Last Name

Date of Birth

YYYY

Home Phone Number

Mobile Phone Number

Postal Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Usual GP & Practice

Medicare Care Card #

Medicare Care Card # (Continued)

# Beside Your Name on Card

Do you have private health insurance?

Yes

Name of Fund

Private Health Fund Member Number

Aged Pensioner Card Number

Aged Pensioner Card Expiry Date

YYYY

Veteran Affairs Car Number

Veteran Affairs Card Number Colour

Next of Kin

First Name

Last Name

Next of Kin Contact Number

Work Cover Claim Number and Case Manager (if applicable)

Employer Name and Contact Number. (if applicable)

Consent for Details to Be Disclosed

As a health care provider in the private sector, the Bone and Joint Clinic is bound by the National Privacy Principles provided in the Privacy Act 1988. These govern how we collect, handle, use, distribute and store personal information collected from our patients at the clinic. Ordinarily we do not release the contents of your file without consent. However, there may be occasions when the law requires us to disclose certain information without your consent. When dealing with other health care professionals, in order to obtain accurate diagnosis or treatment options we will ask your full consent to disclose personal medical details. Please indicate below and sign your consent for details to be disclosed when necessary.

Yes

Give permission for details relating directly to my medical condition to be discussed, if necessary, with other health care professionals.

Signed:

Download the patient registration form

DOWNLOAD

New Patient Registration

Download the patient registration form

BONE + JOINT CLINIC