Toggle navigation
About Us
Our Practice
About Mr Patten
Our Medical Team
Patient Information
Your First Visit
Fees
Request an Appointment
FAQS
Procedures
Hip Arthroscopy
Hip Replacement
Knee Arthroscopy
ACL Reconstruction
Partial Knee Replacement
Total Knee Replacement
Knee Osteotomy
For Referrers
Resources
Contact Us
Patient Registration Form
1
Patient Details
2
Medical History & Medications
3
Consent
Title
Surname
*
First Name
*
Postal Address
*
Street
Suburb
Postcode
Email Address
Occupation
Date of Birth
*
DD
MM
YYYY
Home Phone
Work Phone
Mobile
Medicare & Health Insurance
Medicare Number
Reference Number (To the left of your name)
Expiry Date
Private Health Insurance Fund
Membership Number
Veterans Affairs Card Number
Card Colour
White
Gold
Next of Kin Details
Name
*
Relationship to you
Next of kin phone number
*
Referring Doctor
Doctor's Name
Address
Phone
Fax
Usual GP (if different from referring GP)
Address
Phone
Fax
Physiotherapist (if applicable)
Address
Phone
Fax
I have been diagnosed with a heart condition, e.g. irregular rhythm, heart disease
*
Yes
No
Please Describe
I have a pacemaker and/or defibrillator
*
Yes
No
Type / brand
I have had a heart attack and/or have had surgery on my heart
*
Yes
No
Type of surgery you have had
I have a cardiologist
*
Yes
No
Name
Address
Phone Number
Diabetes
Do you suffer from Diabetes?
*
Yes, type 1
Yes, type 2
No
Is your diabetes controlled by?
Diet only
Tablets
Insulin injections
Current Medications
Do you take any blood-thinning medications?
*
Yes
No
Please list
Have you ever had a bleeding or clotting problem?
*
Yes
No
Have you ever had a stroke or mini-stroke?
*
Yes
No
Please list all your current medications below, if all is not included on your doctor's referral
Do you have any allergies? (ie. medications, tapes, dressings, latex, etc)
Patient Privacy
We require your consent to collect personal information on your behalf. This medical practice collects information for the primary purpose of providing quality health care. We require that you provide us with your personal details and medical history so we may properly assess, diagnose and treat your health care needs.
We will use the information in the following ways:
- Administration purposes in running the practice.
- Billing purposes, including compliance with Medicare, WorkCover & TAC.
- Correspondence with others involved in your care, including your GP, treating doctors, physiotherapists and other specialists.
Consent
I have read the information above and understand the reasons why my information must be collected. I am aware that this practice has a privacy policy regarding patient information.
I understand that I am not obliged to provide any information requested but that failure to do so may compromise the quality of my treatment.
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 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.
Signature
*
Name
*
Date
*
DD
MM
YYYY
Referral Source
How did you hear about Mr Patten?
Google
Facebook
Royal Australian College of Surgeons website
GP/doctor recommendation
Personal recommendation
Other
