MR DUGAL JAMES - PATIENT REGISTRATION FORM

    How did you find out about BOSM? *

    [group other_find_about_bosm]

    If Other, please specify

    [/group]

    Date of your appointment *

    Mr / Dr / Mrs / Miss / Ms

    Surname *

    Name *

    Address

    Post Code

    Phone

    Home

    Work

    Mobile

    Email Address

    D.O.B

    Age

    Occupation

    Next of Kin

    Relationship

    Contact Number

    Person Responsible for Account Payment

    Referring Doctor

    GPs Name

    GPs Address

    Physiotherapist

    Address

    Pharmacy Name

    Pharmacy Address

    Medicare No

    Ref No

    Expiry Date

    Dept of Veteran Affairs No.

    Gold Card

    Expiry Date

    Private Health Insurance Fund Name

    Membership No

    Ref No (number next to your name)

    Are you covered for private hospital admission?

    Are you covered for joint replacements?

    Have you served your waiting period?

    If you are not personally liable for payment of the account, please enter the applicable details:

    Is this a TAC / WorkCover Claim?

    [group yes-IsthisaTACWorkCoverClaim]

    If so, Claim No

    [/group]

    Has the claim been accepted?

    [group yes-Hastheclaimbeenaccepted]

    WorkCover Insurer

    Date of Injury

    [/group]

    Has your medical excess been reached?

    [group yes-Hasyourmedicalexcessbeenreached]

    TAC Case Manager / WorkCover

    Phone

    Fax

    Employer’s Name

    Employer’s Address

    Employer’s Telephone No

    [/group]

    MEDICAL HISTORY

    Current weight:

    Current height:

    Do you suffer from any of the following medical conditions?

    Comments

    Are you allergic to any medicines or tapes?

    [group yes-Areyouallergictoanymedicinesortapes]

    If so, please list

    [/group]

    Please advise if you take any of the following medication (please check):

    [group yes-Ifyestoanyoftheabovemedicationspleasegivereasonwhy]

    If yes to any of the above medications, please give reason why

    [/group]

    Do you take any other medication?

    [group yes-Doyoutakeanyothermedication]

    If so, please list

    [/group]

    Have you had COVID19 in the past 12 months? YesNo

    [group yes-HaveyouhadCOVID19inthepast12months]

    If yes, please list the most recent date of infection (This information is required if you proceed with surgery).

    [/group]

    Have you had any previous surgery or suffered from any serious illness in the past?

    [group yes-illnessfrompast]

    If so, please list including date.

    [/group]

    Please list any other doctors involved in your health care and their address

    Do you smoke?

    Is this a 2nd opinion?

    Have you had an X-ray?

    [group yes-HaveyouhadanX-ray]

    If so, name of imaging provider

    [/group]

    Have you had an ultrasound?

    [group yes-Haveyouhadanultrasound]

    If so, name of imaging provider

    [/group]

    Have you had other imaging?

    [group yes-Haveyouhadotherimaging]

    Please provide details and imaging provider

    [/group]

    PLEASE NOTE YOU MUST BRING ALL IMAGING WITH YOU TO YOUR APPOINTMENT UNLESS ADVISED OTHERWISE

    Patient Signature (Draw your signature with your mouse, tablet or smartphone)

    Date

    The terms of the contract are settlement of all consultation accounts on the same day and surgical accounts 1 week prior.