DL New patient form

PERSONAL INFORMATION
Name: *

Title First name Surname
Preferred name:
Date of birth: *
Occupation: *
Email address: *
example@example.com
Residential address: (including suburb & postcode) *
Postal address: (including suburb & postcode) *
Mobile no: *
Home no:
Work no:
Medicare no: *
Ref no: (located left side of name on the card ie. 1, 2, 3) *
Expiry: *
Health fund: (Please write NIL if uninsured) *
Membership no:
Ref no:
DVA Type:

White Gold
DVA no:
If white, please state DVA disability:
Workcover claim no:
Employer:
Case manager:
Contact no. and email address:
example@example.com
Usual GP: (Please write NIL if you do not have one) *
Clinic: *
Emergency contact name: *
Relationship: *
Phone: *
In the event that I am unable to be contacted, I give permission for the employees of the Gold Coast Centre for Bone and Joint Surgery to speak with and relay information (i.e. surgery particulars, admission times, appointments and office accounting) to the above nominated contact
MEDICAL / SURGICAL HISTORY
Please tick all that apply:

High Blood Pressure DVT/PE Stroke (CVA) Renal (Kidney) Disease Lung Disease/ Asthma Thyroid Disease Diabetes Cardiac Bypass Cardiac Stents Insulin Dependent Oral Medication
This MUST be completed:
Height (ft/cm): *
Weight: *
Other specialists involved in your care:
Previous significant surgery:
Allergies/reactions:
Current medication:
Do you smoke: *

Yes No
Do you drink alcohol: *

Yes No
DISCLOSURE / COLLECTION STATEMENT:
I consent for staff to: *

Identify the practice (i.e. “This is Dr ______ rooms”) Leave a message on answering machine/voicemail
I consent to the disclosure to and collection from medical practitioners, allied health practitioners and hospitals that may require information about my medical/surgical history but only to the extent necessary to assess/treat the condition that I have consulted my orthopaedic specialist about. Disclosure and collection may also be required for administrative purposes for the efficient running of our practice including Medicare, DVA and health funds and non-medical information for debt collection if applicable.
Signature: *

Clear
Date: *

Day Month Year
Date
Should be Empty:

PERSONAL INFORMATION

MEDICAL / SURGICAL HISTORY

DISCLOSURE / COLLECTION STATEMENT: