Patient Registration Form - Dr Charles Gallagher

Patient Details

Title

First name*

Last name*

Address*

Suburb*

Postcode*

Date of Birth*

Occupation

Home Phone

Mobile Phone*

Work Phone

Next of Kin

Full Name

Relationship to Patient

Address

Suburb

Postcode

Phone

Regular General Practitioner’s Details

(NB: ONLY if different to Referring Practitioner and you want them to receive a copy of your results)

Name

Address

Medicare & Health Insurance

Medicare Number

Ref No

Expiry Date

Full Age Pension

Expiry Date

Veteran Affairs Number

Expiry Date

Are you covered by private hospital insurance?*

Yes

Which Fund?

Membership Number

Is this overseas cover?

Yes

Is this cover over 12 months old?

Yes

Are You Claiming Through Workcover?

Yes

Employer’s Name

Employer’s Address

Employer’s Phone

Insurance Company

Insurance Company Address

Insurance Claim Number

Injury Date

Are You Claiming Through The Transport Accident Commission?

Yes

Date of Accident

Claim Number

Claim Manager

Medical History & Medications

Do you have any medical problem

Details of Medical problem

Smoker / Non Smoker

Yes

Any pervious treatments

Surgery

Hand Therapy

Physio

Current Medications

List your current medications

Drug Name

Dosage

Frequency

Do you have any allergies?

Yes

Please specify

Name and contact of guardian

Relationship to Patient

Date of Birth

condition*

I have read and agree to the terms & conditions

I understand that this practice handles personal information in accordance with the National Privacy Principles enshrined in the Privacy Act 1988 (Commonwealth) and as outlined in the Privacy Statement. I consent to the handling of my information by this practice, including via email, fax and postage, for the purpose of providing quality health care, associated administrative and billing purposes, and disclosure for research and quality assurance activities. We take reasonable steps to protect information and your privacy when transmitting your information. We will use post, secure messaging, facsimile, and email, to transmit your information, on request or as appropriate. You acknowledge that email is not a secure form of transmission. We are unable to provide clinical advice to patients via email. I also give permission for medical information to be obtained from any other source in order to help with my treatment.

How did you hear about this surgeon / Orthosport Victoria

Patient Registration Form – Dr Charles Gallagher

Patient Details

Next of Kin

Regular General Practitioner’s Details

Medicare & Health Insurance

Medical History & Medications

Current Medications