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Patient Information Form

To assist us with preparing for your consultation please complete the following online patient information form. This is a secure SSL encrypted online form.

Alternatively, if you do no wish to complete the form online you can download a PDF of the form to complete manually here: Patient Information Form (100k).

Please contact our office on 1300 377 226 if you are unable to complete the form before your visit.

Your Surgeon

Which Surgeon are you seeing?*

Patient details

Title*

First name*

Surname*

DOB*

Occupation

Address

Street*

Suburb*

Postcode*

State*

Contact details

Email address*

Home phone

Work phone

Mobile phone

I do not wish to receive SMS reminders of my appointments.

Next of kin

Name*

Relationship*

Home phone

Work phone

Mobile phone

Referring Doctor

Name*

Date of referral*

Address

Phone

Is your referring doctor also your usual doctor?
NoYes

Usual Doctor's name

Phone

Address

Health insurance

Medicare card No. (no spaces)*

Number left of name*

Expiry*

Private health insurance

Do you have private health insurance?
NoYes

Name of health fund

Membership number

Number next to name (if applicable)

Date joined

Type of coverage

Do you have any exclusions

DVA details

Do you hold a DVA card?
NoYes

DVA number

Colour of card

Work Cover

Is this a Work Cover claim?
NoYes

Date of claim

Claim number

Case manager's name

Case manager's phone

Insurer's name

Phone

Address

Employer's name

Phone

Address

Your Privacy, Our Concern – Consent to Use Your Personal Information

The Sunshine Coast Centre for Orthopaedics complies with the Commonwealth Privacy Act and all other state and territory legislative requirements in relation to the management of personal information. We collect information that is necessary for the provision of your health care. Personal information obtained from you in your consultation may be used to provide information to various health services involved in supporting your health care management (e.g. pathology, radiology, hospitals or other specialists).

I have read and understood The Sunshine Coast Centre for Orthopaedic’s Privacy Policy and understand my rights and responsibilities.

I hereby consent to my personal information being released as and when required.