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Patient Forms

Committed to providing comprehensive and compassionate care to help you regain mobility, alleviate pain, and achieve optimal function.

We require you to complete a Patient Information Form prior to your initial consult. You can do this by:

  • Arriving 10-minutes before your appointment and completing the Patient Information Form in person
  • Completing the form below before your appointment.
  • Downloading and completing the PDF form to bring with you.
    Patient Information Form

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1 Personal Details 2 Health Insurance Details 3 Workers Compensation / MVIT 4 Patient Consent to Use, Collect & Disclose Information
Title
Given Name/s *
Surname *
Date of Birth *
Age *
Postal Address *
Suburb *
Postcode *
Email Address *
Occupation *
Contact Number *
Work Number
Patient Medicare
Medicare Number *Must be 10 Digits
Reference Number *Before your Name
Parent/Guardian Medicare
Full Name *
Date of Birth *Must be 10 Digits
Medicare Number *
Reference Number *Before your Name
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1 Personal Details 2 Health Insurance Details 3 Workers Compensation / MVIT 4 Patient Consent to Use, Collect & Disclose Information
Do you have a Private Health Fund?*
Yes
No
Private Health Fund *
Membership Number *
Ref # *
Does your Private Insurance include Hospital Cover?*
Yes
No
Are you a DVA Gold/White Cardholder?
Yes
No
Card Number *
Do you have a Pension Card?*
Yes
No
What Type?
Card No.

Referral Details

Do you have a Referral?*
Yes
No
Family Doctor *
Referring Doctor *
Suburb/Clinic *
Referring Doctor Suburb/Clinic *
Upload Referral Form
Drag & Drop Files Here Browse Files

Emergency Contact Details

Next of Kin *
Relationship *
Contact Number *
Work / Mobile *

Hospital Admission

Have you been an in-patient or worked in a Hospital / Care Facility in the last twelve months?*
Yes
No
Which Hospital/Care Facility *
Is this appointment regarding a Workers' Compensation or Motor Vehicle Injury?*
Yes
No

Please complete the Form on the Next Page.

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1 Personal Details 2 Health Insurance Details 3 Workers Compensation / MVIT 4 Patient Consent to Use, Collect & Disclose Information
What is this appointment regarding?*
Worker's Compensation
Motor Vehicle Injury

Workers' Compensation WC

Employer Name *
Employer Postal Address *
Employer's Insurance Company *
Claim Number *
Date of Accident *

MVIT - MV

Insurance Company *
Address *
Claim Number *
Date of Accident *

Please Note: If this is a new injury and you do not know the above details, please check with your employer and telephone your surgeon’s rooms with this information as soon as possible.

Failure to pass on this information or rejection of your claim by the insurance company will result in you being personally liable for any invoices raised in the course of your treatment.

Authority For Release of Information

I give permission for you to forward confidential information regarding my injury, the treatment I have received and guidelines for return to work to my employer, insurance company and rehabilitation provider.

This signature confirms I have read, understood and agree with the terms of the above statement.

Signature *
Clear
Date *
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1 Personal Details 2 Health Insurance Details 3 Workers Compensation / MVIT 4 Patient Consent to Use, Collect & Disclose Information

In accordance with the Privacy Act, this practice will ensure your privacy is protected.

Patient Name *

Our staff will use and disclose your personal information for purposes limited to:

  • Referral to another health care provider
  • Sending of specimens, such as blood sample, biopsies
  • Referral to hospital for treatment
  • Advice on treatment options
  • To meet our obligations of notification to our medical defence providers
  • Where legally required to do so, such as producing records to court
  • Account keeping and billing processes

You will have access to your medical records except where it may not be prudent for this access to be given, such as:

  • To provide access would create a serious threat to life or health
  • There is legal impediment to access
  • The access would unreasonably impact on the privacy of another
  • The information relates to anticipated or actual legal proceeding and you would not be entitled to access the information in those proceedings

Multimedia Consent

I consent to multimedia (photos/videos) being taken during procedures (please note: all arthroscopies will automatically have images taken) for the use of improving patient outcomes and training. If I request a copy of my multimedia there will be a nominal cost to me.

Multimedia Consent?*
Yes
No

How we will contact you

I understand that I can choose to have information by email/sms. This service is restricted to administrative purposes only to protect the privacy and confidentiality of patients as total security cannot be guaranteed. In providing and email address/mobile number, I acknowledge the risks and consent for my email.mobile number to be used for this purpose.

Please sign to acknowledge you have understood this form and that you consent to providing medical information to Mr Patrick Michalka.

Signature *
Clear
Name *
Date *

Information Sharing

I consent to the information contained in this form being shared with the HAND AND UPPER LIMB CENTRE

Information Sharing*
Yes
No
Signature *
Clear
Date *
Submit
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