MR DUGAL JAMES - PATIENT REGISTRATION FORM

    How did you find out about BOSM? *
    If Other, please specify
    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
    GP’s Name
    GP’s Address
    Physiotherapist
    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?
    If so, Claim No
    Has the claim been accepted?
    WorkCover Insurer
    Date of Injury
    Has your medical excess been reached?
    TAC Case Manager / WorkCover
    Phone
    Fax
    Employer’s Name
    Employer’s Address
    Employer’s Telephone No

    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?
    If so, please list
    Please advise if you take any of the following medication (please check):
    If yes to any of the above medications, please give reason why
    Do you take any other medication?
    If so, please list
    Have you had any previous surgery or suffered from any serious illness in the past?
    If so, please list including date.
    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?
    If so, name of imaging provider
    Have you had an ultrasound?
    If so, name of imaging provider
    Have you had other imaging?
    Please provide details and imaging provider

    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.