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Conditions & Treatments
Hip
Hip Arthritis
Hip Impingement
Knee
Osteoarthritis Of The Knee
ACL Injury
Meniscus Injury
Recurrent Patellar Dislocation
Foot & Ankle
Syndesmosis Injury
Chronic Ankle Instability
Bunions
Tibialis Posterior Tendon Dysfunction
Hammer or Claw Toes
Plantar Fasciitis
Ankle Arthritis
Hallux Rigidus
Shoulder
Shoulder Arthritis
Rotator Cuff Tear
Frozen Shoulder
Shoulder Dislocation and Recurrent
Elbow
Tennis Elbow
Elbow Arthritis
Distal Biceps Tendon Rupture
Hand Wrist
Base of Thumb Arthritis
Trigger Finger and Thumb
Wrist Fractures
Carpal Tunnel Syndrome
Hand and Wrist Ganglion Cysts
Dupuytren’s Disease
Mallet Finger
Fractures & Trauma
Common Fracture
Limb Reconstruction
Surgeons
Professor Julian Feller
Dr Cameron Norsworthy
Professor Timothy Whitehead
Assoc. Prof. Harvinder Bedi
Dr Robert Steele
Dr Geoffrey Tymms
Dr Rohan Price
Dr Andrew Oppy
Dr Jason Harvey
Dr James Canty
Dr Soong Chua
Dr Lachlan Batty
Dr Julia Kirby
Dr Charles Gallagher
Dr Ruch Dissanayake
Patient Information
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Patient Registration Form – Professor Julian Feller
Orthopaedic Surgeon – Knee Surgeon
MBBS, FRACS, FAOrthA
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Patient Details
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Mrs
Ms
Miss
Mx
Mast
Dr
First name
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Last name
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Address
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Suburb
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Date of Birth
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Occupation
Email
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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
Next of Kin
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Medicare & Health Insurance
Medicare Number
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Expiry Date
Full Age Pension
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Veteran Affairs Number
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Are you covered by private hospital insurance?*
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Which Fund?
Membership Number
Is this overseas cover?
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Is this cover over 12 months old?
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Are You Claiming Through Workcover?
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Employer’s Name
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Insurance Company
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Insurance Claim Number
Injury Date
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Are You Claiming Through The Transport Accident Commission?
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Date of Accident
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Claim Number
Claim Manager
Medical History & Medications
Do you take any of the following medications?
Blood Thinners (Anticoagulants)
Medication For Diabetes
Weight loss medications (e.g. Ozempic)
Current Medications
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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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