SYD HIP & KNEE - New Patient Form

NEW PATIENT FORM
Select the doctor you are seeing*

Dr SolomonDr Broe
Title
Patient First Name
Patient Last Name
Date of Birth

DayMonthYear
Current Date

DayMonthYear
Age
Address
No. / Street
Suburb
State
Postcode
Mobile Phone
2nd Phone
Email Address
Occupation
Medicare No.
Ref No.
No. next to name
Expiry Date
(MM/YY)
Health Fund
Health Fund Membership No.
DVA
Pension No.
Expiry Date
(MM/YY)
Referring Doctors Name
Regular GP’s Name
Physiotherapist Name / Practice
Physiotherapist Email

WORKERS COMPENSATION & THIRD PARTY PATIENTS (CTP)
Insurance Company Name
Claim Number
Case Manager
Case Manager’s Phone
Case Manager’s Fax / Email
Employer
If applicable
Date of Injury

DayMonthYear
PRIVACY STATEMENT

As a patient of Dr Solomon or Dr Broe, a medical record containing personal information will be maintained throughout your treatment. These records will contain information including, but not exclusive to, your name, address, date of birth, Medicare number and your referring doctor’s details. During the period of assessment and ongoing management, information of relevance is recorded in clinical notes. These records are stored securely and may be kept for up to seven years following your last consultation. If necessary, for the continuity of your medical care, this information may be shared with other health practitioners involved in your treatment. In certain circumstances, there may be a legal obligation to disclose clinical information. A full copy of our privacy policy is available on request.

I will take full responsibility for the payment of my accounts.

I give permission for the correspondence to be sent to my GP/specialist or myself electronically via email if required.
Patient Name
Patient Signature

Clear
Date

DayMonthYear