Patient Registration Form - Dr Geoffrey Tymms

Patient Details

Title

First name*

Last name*

Address*

Suburb*

Postcode*

Date of Birth*

Occupation

Home Phone

Mobile Phone*

Referring Doctor Details

Name

Address

GP details (if different from referring Doctor):

Name

Address

Podiatrist/Orthotist Details:

Name

Address

Physiotherapist Details

Name

Clinic

Next of Kin

Full Name

Relationship to Patient

Address

Suburb

Postcode

Phone

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

Smoker / Non Smoker

Yes

Please be aware that smoking causes a significantly increased risk of wound infection and healing problems as well as negatively affect bone healing

Have you had any bleeding, blood clot or DVT problems?

Yes

Are you a diabetic?

Yes

Diabetes Type?

Type1

Type2

Are you taking Insulin for this?

Yes

Do you have any medical problem

Current Medications

List your current medications

Drug Name

Dosage

Frequency

Do you have any allergies?

Yes

Please specify

Section Break

Your Current Symptoms (Pain)

Mid

Moderate

Servere

Pain Duration

Constant

Intermittent

Worse on Movement

How long have you had your current complaint?

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 Geoffrey Tymms

Patient Details

Referring Doctor Details

GP details (if different from referring Doctor):

Podiatrist/Orthotist Details:

Physiotherapist Details

Next of Kin

Medicare & Health Insurance

Medical History & Medications

Current Medications

Section Break