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  • NEW PATIENT FORM

  • Date of Birth
     - -
  • Current Date
     - -
  • WORKERS COMPENSATION & THIRD PARTY PATIENTS (CTP)

  • Date of Injury
     / /
  • 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.

     

  • Date
     / /
  • Problem Area
  • Hip Problems
  • Knee Problems
  • Problem Side
  • Main problem is
  • Was there an injury?
  • Pain Type
  • Pain Frequency
  • Interferes with sleep?
  • Do you need to take pain killers?
  • Rows
  • What investigations have you had?
  • Where did you have your investigations taken?

  • Background Health

  • Allergies to Medications
  • Tick, if you take

  • Do you smoke?
  • Do you drink alcohol?
  • General Medical Conditions (tick, if you have / have had)

  • Previous surgery with a general anaesthetic
  • Date
     / /
  • Should be Empty: