BEISCHER - New Patient Form

Patient Registration Form

MR ANDREW BEISCHER
Patient Details
Title
Surname
Given Name/s
Age
Date of Birth

DayMonthYear
Address
Suburb
State
Postcode
Email Address
Mobile
Home Phone
Business Phone
Next of Kin
Name
Relationship to Patient
Address
Phone
Referring Details
Referred By
Address
Local General Practitioner – if different to referring doctor
Local Doctor
Address
Podiatrist Details
Podiatrist Name
Address
Are you claiming as a: (please tick appropriate box)
Private Health Insurance
Do you have Private Health Cover?
If Yes, Name of Health Insurance Fund
Membership No.
Medicare No.
Ref No.
No. next to name
Expiry
(MM/YY)
WorkCover Details
Employer Name
Employer Address
Date of Injury

DayMonthYear
Insurance Company
Claim Number
Transport Accident Commission (TAC) Details
Claim Number
Date of Injury

DayMonthYear
CHARGES

ALL FEES MUST BE PAID AT THE TIME OF CONSULTATION

Payment can be made by Visa / MasterCard / BankCard / EFTPOS / Cheque or Cash.
- Initial Consultation = $240.00
- Subsequent Consultation = $180.00
REFERRALS

TO OBTAIN MAXIMUM MEDICARE REFUND, A REFERRAL TO MR ANDREW BEISCHER IS REQUIRED

Note: A REFERRAL FROM EITHER A PHYSIOTHERAPIST OR PODIATRIST IS NOT REBATABLE BY MEDICARE.

AI SCRIBE

Please note that this practice uses a secure AI scribe to assist Dr Beischer with the timely preparation of medical chart notes and letters to referring practitioners. If you do not wish to proceed with this, please advise the receptionist immediately before consulting Dr Beischer.
Patient Signature
Date

DayMonthYear
General Medical History
Occupation
Do you smoke?
If Yes…How much & for how long?
Are you an ex-smoker?
If Yes…Please give details
Do you drink alcohol?
If Yes…How much?
Do you suffer from any of the following?
Other Diseases (Please list)
Separate with commas.
Do you take any Medications?
If Yes…What Medications do you take?
Separate each with a comma.
Do you have any ALLERGIES?
If Yes…Please list
Separate each with a comma.
Have you had any RELEVANT operations in the past?
If Yes…What operations have you had?
Current Foot & Ankle Problem
Have you suffered an injury?
When? (approximate date)
How?
Separate each with a comma.
How far can you walk? Please Tick Appropriate Box
Do you suffer pain?
If so, how would you rate your pain? Please Tick Appropriate Box
Does your foot / ankle problem cause difficulty walking on some surfaces? Please Tick Appropriate Box
Are shoes a problem?
What shoes do you wear because of your foot / ankle problem? Please Tick Appropriate Box
How does the foot / ankle problem limit your activities? Please Tick Appropriate Box
Indicate the problems on the diagram if possible
Should be Empty:

Patient Registration Form

Next of Kin

Referring Details

Local General Practitioner – if different to referring doctor

Podiatrist Details

Private Health Insurance

WorkCover Details

Transport Accident Commission (TAC) Details

CHARGES

General Medical History

Current Foot & Ankle Problem