• 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
  • Medicare & Health Insurance

  • Next of Kin Details

  • Referring Doctor

  • Usual GP (if different from referring GP)

  • Physiotherapist (if applicable)

  • Diabetes

  • Current Medications

  • 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.
  • Referral Source

Phone: (03) 9516 2390
Fax: (03) 9516 2394
Email: reception@sampatten.com.au
Epworth Hospital
Suite 8.1, Level 8
89 Bridge Road
Richmond VIC 3121
Regional Health Medical Suites
25 Francis Street
Echuca VIC 3564

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