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Patient Info
GP Referral Form
Operations
Post Operative Instructions
About
Contact
1300 HIP KNEE
1300 447 563
Home
Patient Info
GP Referral Form
Operations
Post Operative Instructions
About
Contact
Home
New Patient Registration
New Patient Registration
Please note: items marked required indicate mandatory fields.
Personal Details
Title
----
Mr
Mrs
Ms
Miss
Dr
First Name
Required
Last Name
Required
Preferred name
Occupation
Date of Birth
Required
Contact Details
Address
Required
Suburb
Required
Postcode
Required
State
Required
----
QLD
ACT
NSW
VIC
SA
WA
NT
TAS
Email
Required
Home Phone
Work Phone
Mobile Phone
Memberships
Medicare Number
Medicare IRN
Medicare Expiry
Private Health Fund Name
Private Health Fund Membership Number
Are you a member of the Department of Veterans Affairs (DVA)?
Yes
No
Emergency Contact
First Name
Last Name
Phone
Relationship
Medical Information
Referring Doctor Name
Referring Doctor Phone
Medical History
Required
Yes – I do have relevant medical history, detailed below
No – I do not have relevant medical history
Existing, diagnosed conditions
Previous operations
Current Medications
Current Vitamins or Dietary Supplements
Allergies
If there are any other specialists that require clinical information please fill the information below.
Specialist Name
Specialist Medical Practice Name
Specialist Phone
Speciality
----
Bariatrics
Cardiology
Colorectal
Dermatology
Ear Nose and Throat
Endocrinology
Gastroenterology
General Surgeon
General Physician
General Practitioner
Neurosurgery
Obstetrics and Gynaecology
Oncology
Ophthalmology
Orthopaedics
Paediatrics
Pathology
Plastic Surgery
Radiology
Spinal
Urology
Vascular - Endovascular
Consent to release medical information I give my consent to Hartley Hip and Knee, or his agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care.
I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Hartley Hip and Knee, or his agents and advisors, as may be requested.
This is in line with the National Privacy Act updated 1st November 2010. For more information view our Patient Information Privacy Statement.
Consent to release medical information
Yes, I consent to the above.
