• Before you complete this form

    Sydney Spine Institute uses Jotform, a US-based online form provider, to collect your information. The personal and health information you enter, including any documents you upload, will be processed in accordance with Jotform’s privacy policy.

    Sydney Spine Institute has taken reasonable steps to assess and manage the privacy risks associated with Jotform and our obligations under Australian privacy law continue to apply.

    For more information, please read Sydney Spine Institute’s Privacy Policy and Jotform’s Privacy Policy.

    If you prefer an alternative method of sending your information to us, please contact Sydney Spine Institute reception on 02 9715 5007.

  • Do you consent to your personal and health information being processed by Jotform for this purpose?*

  • Alternative ways to complete your registration

    You have chosen not to complete your registration through our online form. That's absolutely fine — you can complete your registration using either of the following options:

    Option 1 — Download and return the registration form

    Download our PDF Registration Form, complete and sign it, and return it to us by:

    Email: info@sydneyspineinstitute.com.au
    Fax: 02 9747 6630

    Option 2 — Complete the form at your appointment

    You can complete a paper registration form when you arrive at our clinic. Please allow an extra 5-10 minutes before your scheduled appointment to complete the paperwork.

    If you have any questions or need assistance, please contact our reception team on 02 9715 5007.

     

  • New Patient Registration Form - Sydney Spine Institute

    This form will take about 3-5 minutes to complete. 

    To complete this form you may need:

    • Medicare card
    • DVA card
    • Pension card
    • Referral letter

    Please make sure you have any relevant items ready before you begin.

    All fields marked with an asterisk (*) are required.

  • Personal Information

  • Title*
  • Gender*
  • Date of birth*
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    2 digit day, 2 digit month, 4 digit year
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  • Emergency Contact Information

  •  -

  • Insurance Information

  • Do you have a Medicare card?*
  • Do you have a DVA card?*
  • DVA card type*
  • Do you have a pension card?*
  • Pension card expiry date*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Do you have private health insurance?*
  • Is this consultation related to a work or motor vehicle accident?*
  • Type of accident*
  • Date of injury*
     - -
    2 digit day, 2 digit month, 4 digit year
  •  -
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  • Do you have a Rehab Provider involved in your care?*
  • Do you have an Occupational Physician involved in your care?*
  • Do you have a Physiotherapist or Exercise Physiologist involved in your care?*

  • Referring Doctor & GP Information

  •  -
  • Is the referring doctor the same as your regular GP?*
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  • How did you find out about our practice?*
  • Do you consent to receiving SMS reminders, messages and emails from our practice regarding your appointment or other administrative matters?*

  • Workers’ Compensation & CTP Insurance Disclosure Consent

  • Consent to AI-Assisted Clinical Documentation

  • Some of our clinicians use AI-assisted medical documentation tools, such as Heidi Health and iScribe, to assist with clinical notes during consultations. 

    The software transcribes the conversation to assist your clinician in preparing accurate medical records. All clinical notes are reviewed and verified by your clinician before being added to your medical record. Your information is handled securely and in accordance with Australian privacy laws.

    Participation is voluntary, and you have the right to withdraw your consent at any time.

  • Do you consent to your clinician using AI-assisted medical documentation software (such as Heidi or i-scribe) during your consultation?*

  • Cancellation Policy

  • By signing this form, I acknowledge the practice's cancellation policy, and agree that:

    1. If I am unable to attend my appointment I will give at least 24 hours' notice of my cancellation

    2. If I do not cancel my appointment with 24 hours' notice, I will be charged the fee of my missed appointment

    3. In the event that my accounts are outstanding longer than 45 days, I will be responsible for any additional collection fees incurred 

  • Privacy Statement

  • We are committed to protecting the confidentiality of your personal information and health records.  By signing this form, you:


    1. Acknowledge that we, Sydney Spine Institute, and our service providers, will collect your personal and health information to enable us to provide you with our health services and any related communications (for example, to manage your appointment bookings); 

    2. Consent to our using or disclosing your personal information for purposes directly related to your care and treatment, or in ways that you would reasonably expect that we may use it for your ongoing care and treatment, e.g. disclosing your results to your GP, specialist, other doctor or allied health professional involved in your healthcare; and

    3. Consent to our handling of your personal information in accordance with our Privacy Policy (you can access our Privacy Policy on our website, or by asking us for a copy).

     

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