Patient registration form

Patient Registration Form

PLEASE PRINT
Title: Mr Mrs Miss Ms Ps Dr (Med) Dr (PhD) Other: ___________________________
Surname: ________________________
Given Names: _______________________________

Date of Birth: / /
Occupation: ________________________________________
Home Address:
__________________________________
__________________________________
__________________________________ Postcode:
______________

Mailing Address (if different from above):

__________________________________
__________________________________
__________________________________ Postcode:
_______________

Home phone no.: ___________________ Mobile: _____________________ Work: ___________________
Email:_______________________________________
Next of Kin: ________________________ Relationship: __________________
Tel: __________________
Medicare No.: _ _ _ _ _ _ _ _ _ _ Individual Ref No. (single digit in front of name): _ Exp Date:_ _/_ _ _ _
Health Fund Name: _____________________
Membership No. ______________________

Is this a Workers Compensation Claim or Third Party Claim:
Y / N (please circle)
Insurer:
____________________________ Claim No.: _________________________________
Case Manager: _______________________ Tel:_________________Fax:___________________
Pensioner:
Y / N Type: Aged / Disability / Other Pension No.: _________________ Exp:_________

Veteran Affairs: Y / N Type: Gold / White / Other
Card No.: __________________ Exp: ___________
Usual GP Name: ___________________________
GP Tel: ______________________________
GP Practice and address:
___________________________
___________________________
___________________________
___________________________

If your GP above was not the Referrer, please enter details of Referring Doctor below:
Name:
_______________________________
Address:
__________________________
Tel: _______________________________
__________________________
__________________________

If there are any other interested health Professionals you would like to receive a copy Dr Curtis' clinical reports,
please enter details below:
_____________________________________ ________________________________________
_____________________________________ ________________________________________
_____________________________________ ________________________________________

MEDICAL HISTORY
The information requested below is fully confidential and will be used for the purpose of medical communication, record
keeping and treatment planning only.
Name:______________________________________
ALLERGIES:
Are you allergic to any medications or have you had any allergic reactions in the past?
_________________________________________
___________________________________________ _________________________________________ ___________________________________________
CURRENT MEDICATIONS:

Please list your current medications (unless you have brought a list from your doctor).
___________________________________________
___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________
Are you taking any of the following anticoagulant medications or any other blood thinners?
Aspirin, Cartia, Asasantin, Warfarin, Astarix Plavix, Pradaxa (Please circle) Other: _______________________
PAST SURGERIES:

Operation
____________________________________________ ___________________________________________
____________________________________________ ___________________________________________
____________________________________________ ___________________________________________
MEDICAL CONDITIONS:

Diabetes
Any other medical conditions: ____________________________________________ ____________________________________________ ____________________________________________ FINANCIAL CONSENT

This practice is guided by AMA (Australian Medical Association) fee values and thus there are out-of-pocket costs for
services rendered. A discount is offered for aged pensioners, but we do not bulk bill. Payment for consultation is required
at the time of appointment. All fees are partially recoverable through Medicare. Each consultation is allocated an MBS
(Medicare Benefit Schedule) item number which is dependent on the nature of the appointment, and the actual time and
complexity of the consultation.
Workers Compensation, Third Party and International Insurance patients must provide their insurer details, claim
numbers and case manager details, along with guarantee of payments prior to their appointment. If written guarantee of
payment is not received by the time of the appointment, the patient will be responsible for payment of the consultation at
the time of the appointment, at standard Workers Compensation rates.
If your treatment requires hospital admission, you may choose to be admitted as a private, public or self-insured patient.
Private accounts for surgery are guided by AMA fee values for item numbers used in actual surgery. Therefore only
estimates can be provided for likely out-of-pocket surgical costs. Final costs are dependent on actual surgery performed.
Estimates do not include costs for ancillary services or additional hospital or prosthetic costs. Patients are encouraged to
discuss fee estimates with their health fund providers to ensure adequate hospital and prosthetic cover. Our practice does
not usually participate in no-gap arrangements with health funds.
I accept responsibility for my accounts and agree to the above financial conditions.
Signed by Account Holder: ______________________________________________
Print Name:
______________________________________________ _______________________________________
Dr Jonathan Curtis
Suite 205, Level 2
156 Pacific Highway
Greenwich NSW 2065
PRIVACY CONSENT
To comply with the Privacy Act 2001, all patients need to provide written consent for the following important
aspects of their medical care.
The medical practice collects information from you for the primary purpose of providing quality health care.
We require you to provide us with your personal details and a full medical history so that we may properly
assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in
the following ways:
Administrative purposes in running our medical practice. Billing purposes, including compliance with Health Insurance Commission requirements. Disclosure to others involved in your health care and / or medical claims. This may include treating doctors, specialists, allied health care personnel outside this medical practice and any third party that is involved with your care. This may occur through referral to other doctors, medical tests, reports or results returned to us following referral. To conduct practice audit and medical research, in which case all data is analysed without identifying personal details. Audit and research are important ways of maintaining high standards of medical practice. Audit is a requirement of the Royal Australian College of Surgeons.
Please sign the following declaration:
I have read the information above and understand the reasons why my information must be collected. I am also
aware that this practice has a privacy policy on handling patient information. The practice will not provide
information regarding my medical condition, appointments etc to anyone, including family members, unless I
have agreed to this in writing.
I understand that I am not obliged to provide any information requested of me but that my failure to do so
might compromise the quality of the health care and treatment given to me.
I am aware of my right to access the information collected about me, except in some circumstances where
access might legitimately be withheld. I understand that I will be given an explanation in these circumstances.
Name : _______________________________________________________
Signature: ________________________________ Date: _______________
Dr Jonathan Curtis
Suite 205, Level 2
156 Pacific Highway
Greenwich NSW 2065

Source: http://www.drcurtis.com.au/pdf/patient-registration-form.pdf