MR DUGAL JAMES - PATIENT REGISTRATION FORM How did you find out about BOSM? * Online ResearchRecommended by Friend or FamilySocial mediaBlog / PublicationOther If Other, please specify Date of your appointment * Mr / Dr / Mrs / Miss / Ms SelectMrDrMrsMissMs 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 YesNo Expiry Date Private Health Insurance Fund Name Membership No Ref No (number next to your name) Are you covered for private hospital admission? YesNo Are you covered for joint replacements? YesNo Have you served your waiting period? YesNo If you are not personally liable for payment of the account, please enter the applicable details: Is this a TAC / WorkCover Claim? YesNo If so, Claim No Has the claim been accepted?YesNo WorkCover Insurer Date of Injury Has your medical excess been reached?YesNo 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? High blood pressurePacemakerDiabetes (Please bring a copy of your Enhanced Primary Care – EPC Program to your appointment)Bleeding tendencyBlood clots / thrombosisHepatitisEpilepsyAsthma / breathing problems Comments Are you allergic to any medicines or tapes? YesNo If so, please list Please advise if you take any of the following medication (please check): AspirinIscover / Plavix (clopidogrel)Warfarin If yes to any of the above medications, please give reason why Do you take any other medication? YesNo If so, please list Have you had any previous surgery or suffered from any serious illness in the past? YesNo If so, please list including date. Please list any other doctors involved in your health care and their address Do you smoke? YesNo Is this a 2nd opinion? YesNo Have you had an X-ray? YesNo If so, name of imaging provider Have you had an ultrasound? YesNo If so, name of imaging provider Have you had other imaging? YesNo Please provide details and imaging provider PLEASE NOTE YOU MUST BRING ALL IMAGING WITH YOU TO YOUR APPOINTMENT UNLESS ADVISED OTHERWISE *I hereby authorise Bendigo Orthopaedic & Sports Medicine Clinic to correspond with any medical and / or allied health care providers in relation to my medical problem(s) and treatment. Furthermore, if applicable, I consent to Bendigo Orthopaedic & Sports Medicine Clinic providing clinical details and post-operative reports to the TAC / WorkCover Insurer when requested by them in writing.* 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.