Patient Registration Form

Please complete the following patient registration before your visit, to make the process on the day as simple as possible.

Patient Registration

Your Details

Next of Kin Details

Medicare, Private Health Insurance, DVA Details, Concession Details

If patient under 18 years of age please supply Medicare details and DOB for Parent/Payer so we can send claim online to Medicare

Do you have private health insurance
Veterans Affairs
Do you have a Concession Card (eg. Aged Pension/Disability)

Referring Doctor

Is this your Family Doctor / GP?

Physiotherapist

Do you have a regular physiotherapist?

Other Treating Specialists

Medical History

Checkboxes

Prior Anaesthetic or Surgical Complications

Medication

Oral contraceptive?
Hormone replacement?

Allergies

Alcohol & Smoking

Do you drink alcohol?
Do you smoker?

Work Cover, Compulsory Third Party Details

Is this related to Work Cover, Compulsory Third Party
Has liability been accepted for this injury?
Do you have written prior approval for this consultation from your Insurance Company?

Upload Documents (e.g. GP referrals, Radiology Reports, WorkCover Approval)

Maximum file size: 15MB

pdf, jpeg, png, gif files accepted. Max file size 15mb.

Communication Consent, Information Preferences & Privacy

This practice is, as a health provider in the private sector, bound by the National Privacy Principles and the Health Records and Information Privacy Act 2002 (NSW).  These Principles set the standards by which personal information is collected from patients.  A copy of these Principles is available from the Department of Health or the Australian Medical Association.

As part of your treatment, it is usual to write to your referring Doctor, the Physiotherapist involved in your care, and any other Specialists to whom you are referred, including x-rays MRI’s etc.

In the case of compensation matters it may be necessary to write to the Insurers, Solicitor, and Employer and/or rehabilitation provider.

As outlined in the above mentioned guidelines, only the necessary information will be released.

For quality assurance and research, information may be extracted from you record and held on a specific secure database on occasions.  It may be necessary for us to contact you for ongoing assessment.

ALL PATIENTS TO SIGN: I HEREBY AUTHORISE THE RELEASE OF MY MEDICAL HISTORY TO MY FAMILY DOCTOR/INSURANCE COMPANY/SOLICITOR WHERE APPLICABLE) AND TO TAKE RESPONSIBILITY FOR THE PAYMENT OF ALL ACCOUNTS PRIVATE OR INSURANCE.

Communication & Information Selections

How did you hear about Dr Keeley? *