NEW PATIENT REGISTRATION FORM

If you are a new patient, for your convenience you can complete the new patient registration form online prior to your first visit.

Your selected specialist is Mr Kemble Wang

Patient Information

First Name *

Please provide your first name.

Last Name *

Please provide your last name.

Preferred Name

Date of Birth

Address

Home Phone

Work Phone

Mobile Phone

Occupation

Medicare Number

Patient Reference Number

The number next to your name

Body Part Injured

Left

Right

Both

Next of Kin

Name

Relationship

Telephone

Referring Doctor

Doctor's Name

Provider Number

Address

Other Doctors / Practitioners involved in your care

Local Doctor

Doctor's Name

Address

Physiotherapist or other practitioners involved in your care

Doctor's Name

Speciality

Address

Uninsured Sports insurance

Private Health Insurance (Do you have health insurance coverage for a private hospital)

Yes No

Fund

Membership Number

Veterans' Affairs

File Number

Expiry Date

Workcover/TAC/COMCARE

Claim Number

Claims Agent

Employer

Date of Injury

Fees & Information Consent

Payment for your consultation is required on the day of service. We accept Cash, Cheque, Eftpos, Visa or Mastercard. (Amex and Diners are not accepted). A portion of the consultation fee is rebatable from Medicare (if eligible) and we are able to claim this directly for you with Medicare online.

If surgery is required, you will be provided with an Estimate of Fees.

There usually is a personal Gap Payment (dependent on your insurance cover) and this is payable five working days prior to the procedure.

I understand and accept that it is my responsibility for payment of specialist’s fees in relation to my medical care.
I understand and accept that if any third party insurer (e.g. Health Fund/Workcover/TAC/Comcare) refuses to pay my claim in relation to my medical care, I am personally responsible for payment of your specialist's fees.
I understand and accept that if any overdue accounts are referred to a debt collection agency and/or law firm for collection that I will be liable for the recovery costs & commission incurred.

Name *

Date *

* I agree to MOS terms and conditions

Please agree to the MOS terms.

Information Consent

We require your consent to collect personal information about you. Please read this information carefully, and sign where indicated below.

This medical practice collects information from you for the primary purpose of providing quality health care.

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.

Administrative purposes in running our medical practice.
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
Disclosure to others involved in your health care, including treating doctors and 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 the referrals.

I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information.
I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me.
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 an explanation in these circumstances.
I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.

Name *

Date *

* 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 of which I may notify this practice.

Please give your consent.