Riverside Orthopaedics - New Patient Form
  • NEW PATIENT REGISTRATION FORM

    Mater Medical Suite 1. 76 Willetts Road North Mackay Qld 4740
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  • Next of Kin

  • REASON FOR VISIT

  • IS YOUR PROBLEM RELATED TO INJURY

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  • WORKCOVER/WORKPLACE INJURY DETAILS

    (Complete only if injury occurred at work)
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  • HAVE YOU HAD ANY IMAGING

  • Have you had any previous Orthopaedic Surgery?

  • PAST MEDICAL HISTORY

  • PRIVACY ACKNOWLEDGEMENT AND CONSENT

  • This practice complies with the Australian Privacy Principles under the Privacy Act 1988 (Cth) and the Information Privacy Act 2009 (Qld). We are committed to maintaining the privacy and confidentiality of your personal and health information. Further details are available in our Privacy Information for Patients.

    Use of Your Information

    Your personal and health information may be collected, used, and disclosed
    for the following purposes:

    • To communicate relevant information with the healthcare providers involved in your care (e.g. your GP, specialists, or allied health professionals)
    • To enable doctors within this practice to provide appropriate care
    • For billing and administrative purposes, including Medicare and private health insurance claims
    • Where required or authorised by law
    • For research purposes using de-identified information only

    Your Consent

    By signing below, you:

    • Acknowledge that you have read and understood this information
    • Consent to the collection, use, and disclosure of your personal and health information as outlined above
    • Accept financial responsibility for all services provided, whether payable privately or through a third party, including WorkCover
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