BERGMAN - New Patient Form

PATIENT DETAILS

TITLE*

SURNAME*

FIRST NAME*

MIDDLE NAME

ADDRESS*

SUBURB*

STATE*

POSTCODE*

EMAIL*

HOME PHONE

Enter phone no. with area code included. No spaces please.

WORK PHONE

Enter phone no. with area code included. No spaces please.

MOBILE PHONE

Enter your full mobile number. No spaces please.

DATE OF BIRTH*

AGE*

MEDICARE CARD NO

10 digits

REFERENCE NO

1 digit next to cardholder's name

EXPIRY

(MM/YY)

PRIVATE HEALTH INSURANCE

HEALTH FUND

eg. HCF, NIB, Bupa

MEMBER NO

LEVEL OF COVER

DEPARTMENT OF VETERANS AFFAIRS

VX NUMBER

CARD COLOUR

MEDICAL INFORMATION

ALLERGIES

Please list and separate with commas.

REFERRING DOCTOR

REFERRING DOCTOR ADDRESS

FAMILY DOCTOR

If different from the referring doctor.

FAMILY DOCTOR ADDRESS

If different from the referring doctor.

RADIOLOGY TESTS

Please provide details of recent radiology tests performed in preparation for your appointment with Mr Bergman.

RADIOLOGY TESTS

IMPORTANT

FEE POLICY
Have you read Mr Bergman’s fee policy? A copy can be obtained from the receptionist or at www.neilbergman.com.au

PRIVACY POLICY
From 12/3/2014, the Privacy Act 1988 has been amended by the Privacy Amendment (Enhancing Privacy Protection) Act 2012. The Australian Privacy Principles (APP) require that fully informed voluntary consent is obtained before or as soon as practical after the collection of health information.

Medical care requires full knowledge of patient health information by all members of a medical team. Your information may be shared with other health providers from time to time. This may include referring doctors, pathology laboratories, radiology practices, anaesthetists, other health providers and debt collection agencies. Some information may also be provided to Medicare, and Private Health funds, if relevant, for billing and Medicare rebate purposes.

Health information may be used for “secondary purposes” such as auditing surgical results, clinical research etc. These activities should be a normal part of good surgical practice. Record keeping for orthopaedic surgery may also include radiographs and clinical photographs. The privacy of individual patients is strictly maintained when reporting results of audits or research to the profession. You may request access to your records.

A copy of our privacy policy is available from the receptionist. Please discuss concerns about the privacy of your personal information with Mr Bergman

I,

Patient Name

have read and understood the fee policy and the outline of the privacy policy, and consent to information, Xrays and photographs being used for the “secondary purposes” of Audit and Research by Mr Bergman and his associates.

I also give my permission to be contacted for clinical research projects, understanding that it is my decision whether or not to participate and that my treatment will not be influenced by this decision.

SIGNATURE*

Please sign with mouse, touch pad or finger.

RELATIONSHIP TO PATIENT

If, guardian.

DATE

Date

PLEASE VERIFY YOU'RE HUMAN*

NEW PATIENT REGISTRATION

PATIENT DETAILS

PRIVATE HEALTH INSURANCE

DEPARTMENT OF VETERANS AFFAIRS

MEDICAL INFORMATION

RADIOLOGY TESTS

IMPORTANT