Riverside Orthopaedics - New Patient Form

Referred by:

Referrer Type: GP / Physio / Specialist /Other

Referral Letter

GP Name & GP Practice Name:

Address & Phone Number:

Name of Physiotherapist / Other & Name of their Practice:

Address & Phone Number:

Is the patient a child 14 years and under?*

YESNO

Parent Name*

Date of Birth*

Date

Medicare No.*

Number before your name on the Medicare card*

Expiry Date*

Date

Practice Privacy Policy and Consent
This practice is, as a health provider in the private sector, bound by the National Privacy Principles and the Health Records and Information Privacy Act 2002 (NSW) and with strict confidentiality guidelines by the National Privacy Principles defined under the Privacy Act 1998 and as outlined in the Mater Hospital Brochure, “Privacy Information for Patients”.

These Principles set the standards for collecting personal information from patients. A copy is available from the Department of Health or the Australian Medical Association.

As part of your treatment, it is usual to write to your referring Doctor, the Physiotherapist involved in your care, and any other Specialists you are referred to, including imaging results, etc.

Regarding compensation matters, writing to the Insurers, Solicitor, Employer, and rehabilitation provider may be necessary. As outlined in the guidelines above, only the essential information will be released.

Your personal health information and medical records may be collected, used and disclosed for the following purposes.

For communicating relevant information with others involved in your care, including your GP, other specialists or allied health professionals
For use by all doctors in this practice when consulting with you
For Billing purposes/ Medicare /Health Insurance procedures
For legal-related disclosure as required by a court of law
For research only where de-identified information is used

Consults may be recorded.

Information may be extracted from your record and held in a secure database occasionally for quality assurance and research. We may also need to contact you for an ongoing assessment.

Unless otherwise indicated

I acknowledge that I have read and understood the information above by signing below.

I allow my personal and health information to be collected, used and disclosed as described above. I know that only my relevant personal information will be provided. I can withdraw, alter, or restrict my consent by notifying the practice in writing.

I AGREE TO TAKE RESPONSIBILITY FOR THE PAYMENT OF ALL ACCOUNTS, PRIVATE OR INSURANCE.

Printed Name

Relationship to patient, if not patient signing

Signature

Date

DayMonthYear

	Name	Reason Taken	Dose (mg)	Frequency
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PATIENT INFORMATION FORM

PERSONAL DETAILS

NEXT OF KIN

OCCUPATION

PRACTITIONER DETAILS

MEDICARE

PRIVATE HEALTH INSURANCE

PENSION CARD/HEALTH CARE CARD

VETERAN AFFAIRS

	Test Type (Xray, MRI, Bloods, Other)	Company	Date (Year)
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	Body Area	Treatment/Operation	Year
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