Patient Registration

Personal Details

Name*

Gender*

Male
Female
Other

Date of Birth*

Address*

Suburb*

Postcode*

Phone Number

(Preferred Contact Number)*

Email*

Occupation

Emergency Contact / Next of Kin

Name

Contact number

Relationship to patient

Account Details

Medicare Card Number

Medicare Reference Number (number beside your name)

Medicare Card Expiry

Pension Card Number

Pension Card Expiry

Health Care Card Number

Health Care Card Expiry

Private Health Insurance

Name of Health Fund

Membership Number

DVA Card number

lf TAC/Workcover

Claim number

Employer

Date of Injury/Accident

Insurance Company

Correspondence Details

(Please enter GP details or tick box)

Upload Referral

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as per referral

as per referral (No need to enter GP details)

General Practitioner

Address

Suburb

Postcode

Physiotherapist / Other Therapist (if you would like them to receive a copy of your correspondence)

Address

Suburb

Postcode

Medical History

As per Referral

As per Referral

Medical Details

Medications

Disease

Diabetes
DVT-PE (clot)
Asthma
Cardiac/Heart condition

If using blood thinners, please specify:

Previous Anesthetic Issues

Yes
No

Allergies

How did you find out about us?

GP
Another doctor
Physiotherapist or other therapist
Friend/Family member
Internet
Hospital/Hospital Staff member
Other

Other

Privacy consent form:*

I acknowledge that I have read and understood the following summary of the OrthoSport Victoria Practice Privacy Policy, including:

The types of personal information collected by the practice, the reasons why it is necessary to collect it and the circumstances in which my personal information may be used or disclosed;
That I may request access to my personal information, which may be granted in accordance with the practice’s Access to Personal Information Policy. \ will be provided with a written reason if access is denied;
That I may request an amendment to my personal information if it is incorrect. I will be provided with a written reason if a request for amendment is denied;
That my personal information will not be used for direct marketing or disclosed to overseas recipients;
That de-identified scans, clinical images and data may be collected and used for presentations, research and educational purposes;
That I am not obliged to provide the practice with my personal information, but withholding information may limit the practice’s ability to provide me with full service;
That I have the right to lodge a complaint about the handling of my personal information if I am dissatisfied, which will be dealt with in accordance with the practice’s complaint handling procedure
That I may obtain a copy of the complete policy from the website or from the rooms on request.

Please tick to receive an email notification.

Please tick to receive an email notification.

Signature*

Date*

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Name

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Personal Details

Account Details

lf TAC/Workcover

Correspondence Details

Medical History

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Locations

Contact Details

Hours

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