CALL US 07 3059 6259
EMAIL US reception@badeortho.com.au

Patient Registration Form

Patient Details

First Name *
Last Name *
Date of Birth
Age

Address

Address Line 1
Address Line 2
City
State
Postcode
Home Phone (inc area code)
Mobile Phone
Work Phone
Email Address *
Medicare Number
Ref
Expiry
Workcover Claim
Private Health Fund
Membership Number
DVA
Gender
Marital Status
Next of Kin
Phone Number
Regular GP
Practice Name
Phone Number
Do you have any allergies, if YES, please list:
Are you currently on any regular prescription medications (ie Warfarin, Xarelto etc)?
Do you regularly take over the counter Vitamins (ie Fish Oil capsules etc)?
Do you suffer from Diabetes
If yes, what dose of injectable insulin are you using?

If the patient is under 18 years of age please provide the following information:

Parent / Guardian Name
Parent / Guardian Medicare No
Parent / Guardian Ref

Medicare Expiry
Parent/Guardian DOB

PRIVACY INFORMATION & CONSENT

As a patient of our medical practice, 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 aim to protect the privacy of your health and personal information. You can request a copy of our practice privacy policy, which includes information about the collection, use and disclosure of your health information. We require your consent to collect your personal information, and for its use in the following ways:

  • Administrative purposes;
  • Billing purposes (including compliance with Medicare and Health Insurance Commission requirements);
  • Disclosure to others involved in your healthcare. This includes your treating Doctor and other 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 referrals;
  • For research and quality assurance activities to improve individual and community health care and practice management. Only information that does
    not identify you is used in these circumstances;
  • To comply with any legislative or regulatory requirements, such as notifiable diseases;
  • For reminders and recalls which may be sent to you regarding your health care and management.
    By signing this privacy information and consent document, I consent to having my information transmitted electronically to authorised third parties. Additionally, I consent to the handling of my information by this practice for the purpose set out above.
Name *
Signature *
Clear
Use your mouse or finger to draw your signature above
Date *