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Patient Registration Form – Dr James Canty
Orthopaedic Surgeon – Knee & Hip Surgeon
MBBS, FRACS, FAOrthA
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Patient Details
Title
Mr
Mrs
Ms
Miss
Mx
Mast
Dr
Date of Birth
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DD dash MM dash YYYY
Given Name
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Preferred Name
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Surname
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Address
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Suburb
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Postcode
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Occupation
Home Phone
Mobile Phone
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Email
Referring Doctor
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Consult letter
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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
Aged Pension Number
Expiry Date
DD slash MM slash YYYY
Veteran Affairs Number
Card Colour
Expiry Date
Guardian Name (If patient is under 16 years of age)
Are you covered by private hospital insurance?*
Yes
No
Which Fund?
Membership Number
Is this overseas cover?
Yes
No
Are You Claiming Through Workcover?
Yes
No
Employer’s Name
Employer’s Address
Employer’s Phone
Insurance Company
Insurance Company Address
Insurance Claim Number
Injury Date
MM slash DD slash YYYY
Are You Claiming Through The Transport Accident Commission?
Yes
No
Date of Accident
MM slash DD slash YYYY
Claim Number
Claim Manager
Medical History & Medications
Do you take Aspirin / Cartia?
Yes
No
Do you take any of the following medications?
Warfarin
Clexane
Eliquis
Xarelto
Plavix
Are you diabetic?
Yes
No
If so, what type?
Are you on Ozempic (semaglutide)?
Yes
No
If so, when was your last injection?
MM slash DD slash YYYY
Have you ever had a bleeding or clotting problem?
Yes
No
Do you have a pacemaker?
Yes
No
Do you have a cardiologist? (Name and contact details)
Do you have any other relevant specialists (e.g. Neurologist, Rheumatologist)? (Name and contact details)
Do you have allergies?
Yes
No
If yes, please list in detail (e.g. medications, latex, adhesives, etc)
Consent
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.
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I have read and agree to the terms & conditions
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Date
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How did you hear about this surgeon / Orthosport Victoria
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