NEW PATIENT REGISTRATION Required fields * Select Specialist PATIENT INFORMATION First Name Last Name Preferred Name Date of Birth Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Month January February March April May June July August September October November December Month Year 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 Address Home Phone Work Phone Mobile Phone Occupation Email Medicare Number Patient Reference Number The number next to your name Body Part Injured Body Part Left Right Both NEXT OF KIN Name Relationship Telephone REFERRING DOCTOR Doctor's Name Provider Number Address OTHER DOCTORS / PRACTIONERS INVOLVED IN YOUR CARE Local Doctor Doctor's Name Address Physiotherapist or other practitioners involved in your carer Doctor's Name Speciality Address INSURANCE DETAILS Insurance Uninsured Sports Insurance Private Health Insurance (Do you have health insurance coverage for a private hospital) Yes No Veterans' Affairs File Number Expiry Date Workcover/TAC/COMCARE Claim Number Claims Agent Employer Date of Injury Medical History Smoker High Blood Pressure Diabetic Heart Disease Cancer Cancer Type (Please specify cancer type) Other Illnesses Allergies Do you take any of the following medications Warfarin PlavixIscover Clopidogrel Prednisolone Aspirin MethotrexateInsulin FEES Fees & Information Consent Payment for your consultation is required on the day of service. We accept Cash, Eftpos, Visa or Mastercard. (Amex and Diners are not accepted). A portion of the consultation fee is rebatable from Medicare (if eligible) and we are able to claim this directly for you with Medicare online. If surgery is required, you will be provided with an Estimate of Fees. NO gap fees are charged in this practice. I understand and accept that it is my responsibility for payment of specialist’s fees in relation to my medical care. I understand and accept that if any third party insurer (e.g. Health Fund/Workcover/TAC/Comcare) refuses to pay my claim in relation to my medical care, I am personally responsible for payment of your specialist's fees. I understand and accept that if any overdue accounts are referred to a debt collection agency and/or law firm for collection that I will be liable for the recovery costs & commission incurred. Name Date AGREE TO TERMS AND CONDITIONS I agree to West Gippsland Orthopaedics Terms and Conditions INFORMATION DETAILS Information Consent We require your consent to collect personal information about you. Please read this information carefully, and sign where indicated below. This 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. 1/ Administrative purposes in running our medical practice. 2/ Billing purposes, including compliance with Medicare and Health Insurance Commission requirements. 3/ Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals. 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. 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 I will be given an explanation in these circumstances. I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained. Name Date CONSENT I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice. Submit New Patient Registration Form Andries de Viliers is a highly accomplished orthopaedic surgeon with a long standing commitment to outstanding patient care.