Patient information form.Please complete this form to provide your personal details to the Wesley Orthopaedic & Sports Injury Clinic. Surname * Given Names * Preferred Name Prefix Miss Ms Mrs Master Mr Dr Date of Birth * Email * Mobile Phone * Home Phone Work Phone Address * Suburb * Postcode * Occupation Medicare Number * Medicare Reference Number * DVA Number Private Health Insurance * Yes No Name of Health Fund Membership Number Level of Cover Full Private Cover Extras Only Have you served the 12 month waiting period? Yes No Name of Usual General Practitioner (GP) GP Location Are you on any medications that thin your blood to stop clotting? * Examples include aspirin, Cartia, Plavix, Clopidogrel, warfarin, Apixaban or Eliquis Yes No Unsure Are you on the oral contraceptive pill? * Yes No Don't wish to answer Are you on hormone replacement therapy? * Yes No Don't wish to answer Do you have diabetes? * Yes No Next of Kin Relationship Next of Kin Phone Number I consent to the Wesley Orthopaedic & Sports Injury Clinic Doctors and Staff releasing my health information in the event of being approached by my next of kin or nominated person/s e.g. confirm appointments, leave phone messages, check radiology / pathology results, relevant pre/post operation information etc * Yes No I consent to the Wesley Orthopaedic & Sports Injury Clinic Doctors and Staff contacting me on my nominated contact numbers using their Practice name. * Yes No Privacy Policy I have read the information above and understand the reasons why my information must be collected. I am also aware that the Wesley Orthopaedic and Sports Injury Clinic has a Privacy Policy on handling patient information. * Yes No I understand that I am not obliged to provide any information requested of me, but my failure to do so, might compromise the quality of the health care and treatment given to me. * Yes No 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 a reasonable explanation in these circumstances. * Yes No 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 that I notify this practice in writing. * Yes No Thank you!
