MELB ARTHRITIS PHYSIO - New Patient Form

PHYSIOTHERAPY PATIENT REGISTRATION
PERSONAL INFORMATION
Title

MrMrsMsMissDrOther
Surname
First Name
Date of Birth

DayMonthYear
Phone: Home
Mobile
Email Address
Address
No. / Street
Suburb
State
Postcode
Current Date

DayMonthYear
Age
NEXT OF KIN
Next of Kin Contact Name
Contact Home
FINANCIAL INFORMATION
Medicare No.
Ref No.
No. next to your name
Expiry Date
(MM/YY)
Private Health Fund
Membership No.
Extras

YesNo
DVA

GoldWhite
Number
REFERRING DOCTOR
Doctor's Name
Address
MEDICAL HISTORY
Do you have any of the following (if YES, please tick appropriate box):

Autoimmune diseaseLupusRheumatoid arthritisMultiple SclerosisFibromyalgiaChronic fatigue syndromeMigraineHeart problemHigh /Low blood pressurePacemakerCanal stenosisBruise easilyBlood clot/ EmboliOsteoarthritisOsteoporosis(low density)Knee replacementHip replacementShoulder replacementArthroscopyDisc herniationHIVHepatitis B / CCancerDepressionAsthma/COPDDiabetesAllergyStrokeSeizures/FaintAnxietyBalance deficiency/FallOther
Please read and tick the boxes if agree:
Please read and tick the boxes if agree:

Authority for us to choose and alter the treatment.
I authorise my therapist to choose and change my treatment during the course of treatment in Melbourne Arthritis after discussing with me. Following the assessment, different types of treatments may be suggested by the therapist to optimize the result of the treatment. This includes using Low-level laser therapy, Electro Shockwave therapy, Dry needling, Ultrasound, Emsella, EMSCULPT or other equipment, which will be explained and discussed prior to the use of them.
Authority for us to provide your information tonecessary health care providers.
I authorise Melbourne Arthritis to provide my information about my personal care to other health care providers for the purpose of optimising my health care management. Melbourne Arthritis will maintain ownership of this information and will release only such information as is deemed for care provision.
Authority to release personal information to us.
I authorise Melbourne Arthritis to obtain and access all of my medical and other information required for my care. I consent to the release of medical, clinical or other information by any medical practitioner, hospital, and clinic, an insurance company, Centrelink, the Department of Defence or other organisation appear to be relevant.

I understand that by signing this form it will mean that Melbourne Arthritis and delegates will be able to ask any person who holds information about you to disclose that information if that information seems relevant to providing my medical care.

In general, this form will be used to access your medical records in the possession of other Practitioners and Hospitals.
Authority to receive sms and email from Melbourne arthritis
This authorises Melbourne Arthritis to send you SMS reminder and new treatment option information if required.
A signature from one of the parents or authorized person is required for treating of a minor(the patient under 18 years old age).

I consent to Melbourne Arthritis practitioners to perform treatment upon myself.
Patient Name
Patient Signature

Clear
Date

DayMonthYear
Should be Empty:

PHYSIOTHERAPY PATIENT REGISTRATION

PERSONAL INFORMATION

NEXT OF KIN

FINANCIAL INFORMATION

REFERRING DOCTOR

MEDICAL HISTORY

Please read and tick the boxes if agree:

A signature from one of the parents or authorized person is required for treating of a minor(the patient under 18 years old age).

I consent to Melbourne Arthritis practitioners to perform treatment upon myself.