New Patient Form Mr Vishal Pai

New Patient Registration Form
Thank you for completing our new patient registration questionnaire. It is necessary to complete this questionnaire prior to your appointment as this will give Mr Pai more time to focus on your knee condition. If you have any questions or concerns, please contact 03 8657 0595 for assistance.
Contact Details
Name*

PrefixGiven NamesSurname
What is your gender?

ManWomanNon-binaryPrefer not to sayOther
Date of Birth*

DayMonthYear
Date
Occupation
Today's Date

DayMonthYear
Date
Age
Telephone
Mobile*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

SuburbState

Postal Code
Emergency Contact Details
Emergency Contact Name*

First NameLast Name
Relationship*
Emergency Contact Mobile*

Account details
Medicare Number*
If you do not have a Medicare number, please enter zeros to fill out this section.
Individual Reference Number*
A number that represents the position of a person on a Medicare card. The IRN appears to the left of the patient's name on their Medicare card.
Medicare Expiry*
As the patient seeing Dr Pai is under 18, we will need the name and individual reference number for one of the parents to process Medicare reimbursements. Medicare links bank account details for rebates to the parents' accounts.
Parent's Name

First NameLast Name
Parent's Date of Birth

DayMonthYear
Parent's Individual Reference Number
What is your preferred location for appointments*
We will always try our best to accomodate your preference where we can. Sometimes, due to availability, we might book for you to see Dr Pai at another location if the situation is time critical.
Do you have private health insurance?*
Does your health insurance policy include hospital cover?

YesNo
What level of hospital cover do you have?
Have you had hospital cover for more than 12 months?
Fund Name
If your fund is not listed in the dropdown menu, please select "Not Listed" and manually enter the fund name.
Membership Number
Non-listed Fund Name
Are you a veteran (DVA)?*
DVA Number
DVA Card Type
Is this case related to Workers Compensation?*
Date of Injury

DayMonthYear
WorkSafe Claim Number
WorkSafe Insurer
Case Manager Name

First NameLast Name
Case Manager Email
example@example.com
Is this case related to the Transport Accident Commission?*
Date of Injury

DayMonthYear
TAC Claim Number

Medication, Allergy & Social History

The information you provide will assist Mr Pai to provide optimum care for you. All staff are bound by confidentiality agreements to maintain your privacy.
Do you take regular medications?*
If yes, which ones:
Please include a complete list of medications you currently take as sometimes, the GP referral may not be accurate.
Do you regularly take:

WarfarinClopidogrel (Plavix)AspirinApixaban (Eliquis)Rivaroxaban (Xarelto)Other blood thinners
Are you taking the oral contraceptive pill?*
It is important for Mr Pai to be aware of this as it may increase the risk of clots in the leg if you require surgery.
Are you on hormone replacement therapy?*
It is important for Mr Pai to be aware of this as it may increase the risk of clots in the leg if you require surgery.
Are you taking weight loss medication?*
It is important for Mr Pai to be aware of this as it may increase the risk of anaesthetic and need to be withheld if you require surgery.
Which weight loss medication do you take:*
Do you regularly take herbal medications?
We ask for this information because some herbal medications can interact with prescribed drugs and others can act as a blood thinner.
If yes, which ones:
Do you have drug allergies?*
If yes, please specify which drugs you are allergic to and the type of allergy?
Allergies can be classified as a rash, swelling around the mouth, shortness of breath or anaphylaxis.
Are you allergic to the following?

LatexIodineChlorhexidine
Your body mass index (BMI) can affect your knee pain, increase the risk of specific conditions and affect the risk of surgery. Please provide your most recent weight and height measurements.
What is your weight (kilograms) and height (centimetres)?*
Do you drink alcohol?
How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day when you are drinking?
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?
Alcohol Screening Score
A score of less than 5 indicates lower risk drinking.
Do you smoke cigarettes?*
If yes, how many cigarettes per day?
How many years have you smoked for?
Pack years of smoking

New Patient Registration Form

Contact Details

Emergency Contact Details

Referral details

Account details

Medication, Allergy & Social History

Previous imaging

Medical Checklist