Patient Registration Form

Are You a Patient?

New Patient Returning Patient

Choose Your Specialist

Telephone Numbers

Next of kin details (family member or friend / medical power of attorney)

Next of Kin Contact number

Medicare & Health Insurance

Private Health Insurance

Yes No

Veterans Affairs Card

Yes No

Public / Uninsured Patient

Yes No

Do you have any allergies? (ie Medications / Tapes / Dressings / Latex / Contrast)

Yes No

If yes please list and include details of reaction

HEART / CARDIAC CONDITIONS

CARDIAC: PACEMAKERS and/or IRREGULAR HEARTBEAT

I have had an irregular heartbeat or palpitations

Yes No

Do you have a pacemaker and /or defibrillator?

Yes No

Do you have a Cardiologist?

Yes No

Cardiologist’s Name

Cardiologist: Address & Contact Details

I have been hospitalised for a heart attack and/or have had surgery on my heart:

Yes No

If yes

Stent Bypass Surgery Valve

BLOOD-THINNING MEDICATIONS

Do you take Asprin / Cartia?

Yes No

Do you take any of the following medications? (please tick)

Have you ever had a bleeding or clotting problem?

Yes No

Have you ever had a stroke or mini-stroke/TIA?

Yes No

Do you suffer from Diabetes?

Yes No

If Yes, is your Diabetes controlled by:

Diet Only Tablets/Medication Insulin Injections

Do you take any of the following medications? (please tick)
Metformin Combinations:

Metformin/Empagliflozin (Jardiamet) Dapagliflozin (Forxiga) Metformin/Dapagliflozin (Xigduo) Empagliflozin (Jardiance)

Do you have a Endocrinologist?

Yes No

Endocrinologist’s Name

Endocrinologist: Address & Contact Details

Do you have a Rheumatologist?

Yes No

Rheumatologist’s Name

Specialist’s: Address & Contact Details

Other medical practitioners

MEDICATIONS - Anti-inflammatory (NSAIDs) &/or Disease Modifying Drugs

Do you take any of the following medications? (please tick)

(if yes, list name and method below)

ALL CURRENT MEDICATIONS &/or SUPPLEMENTS

Please list ALL medications:(include aspirin, cortisone, steroids, anti-inflammatory, anticoagulants, herbal products and over-the-counter preparations, including the previously mentioned medications in this form )

Drug / Supplement name

PREVIOUS OPERATIONS

Please list previous surgical procedures

Have you ever had problems with an anaesthetic previously?

Yes No

If yes, please describe

BODY PART(s) INJURED / AREA of CONCERN

Select the affected area

Click one or more areas on the diagram below.

Selected areas:

None selected

TELL US BRIEFLY ABOUT YOURSELF AND YOUR CONDITION

History of Injury (e.g. fell whilst playing sport)

Your Current Symptoms
Pain

Mild Moderate Severe

Pain Duration

Constant Intermittent Worse on movement

Do You Experience

Swelling Weakness Numbness

Normal Work / Sporting Activities

What Aggravates Your Symptoms?

What Relieves Your Symptoms?

How Far Can You Walk?

Previous Bone or Joint Surgery

Please List Any Specific Concerns / Questions You have regarding your injury/condition

CONSENT

Please read this information carefully and sign where indicated below.
Our medical orthopaedic practice collects information for the primary purpose of providing quality health care. Thank you for providing us with your personal details and a full medical history so that we can assess, diagnose, treat and be proactive in your health care needs.

This information may be used in the following ways:

Administration purposes in running our orthopaedic practice.
Billing purposes, including compliance with Medicare, Health Insurance Commission, Workcover and Transport Accident Commission requirements.
Disclosure and referrals to other healthcare providers, including treating doctors, physiotherapists, and other specialists or orthopaedic company representatives. This includes medical investigations, app registration and data collection to support your clinical care.

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 may compromise the quality of 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.

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 that I notify this practice of.

Name: (Please type your full name. By doing so, you agree that this constitutes your electronic signature.)

I consent to participate in research

Yes No

I am willing to participate in the collection of data for research purposes. (All data is de-indentified)

Name: (Please type your full name. By doing so, you agree that this constitutes your electronic signature.)

How did you hear about us?

Personal recommendation:

PLEASE NOTE: All Appointments, Enquiries & Correspondence to our Richmond Practice Only
Melbourne Orthopaedic Clinic 15 Erin Street RICHMOND VIC 3121 | Tel: (03) 9421 6199 | Fax: (03) 9421 6114 | Email: admin@moc.com.au

Choose Your Specialist

Telephone Numbers

Next of kin details (family member or friend / medical power of attorney)

Next of Kin Contact number

Medicare & Health Insurance

Private Health Insurance

Yes No

Veterans Affairs Card

Yes No

Public / Uninsured Patient

Yes No

Do you have any allergies? (ie Medications / Tapes / Dressings / Latex / Contrast)

Yes No

If yes please list and include details of reaction

Conditions

CARDIAC: PACEMAKERS and/or IRREGULAR HEARTBEAT

I have had an irregular heartbeat or palpitations

Yes No

Do you have a pacemaker and /or defibrillator?

Yes No

BLOOD-THINNING MEDICATIONS

Do you take Asprin / Cartia?

Yes No

Do you take any of the following medications? (please tick)

Do you suffer from Diabetes?

Yes No

If Yes, is your Diabetes controlled by:

Diet Only Tablets/Medication Insulin Injections

Do you have any additional specialists managing your care?

Yes No

Specialist’s: Address & Contact Details

BODY PART(s) INJURED / AREA of CONCERN

Select the affected area

Click one or more areas on the diagram below.

Selected areas:

None selected

TELL US BRIEFLY ABOUT YOURSELF AND YOUR CONDITION

ALL CURRENT MEDICATIONS &/or SUPPLEMENTS

Please list ALL medications:(include aspirin, cortisone, steroids, anti-inflammatory, anticoagulants, herbal products and over-the-counter preparations, including the previously mentioned medications in this form )

Drug / Supplement name

PREVIOUS OPERATIONS

Please list previous surgical procedures

Have you ever had problems with an anaesthetic previously?

Yes No

If yes, please describe

CONSENT

Administration purposes in running our orthopaedic practice.
Billing purposes, including compliance with Medicare, Health Insurance Commission, Workcover and Transport Accident Commission requirements.
Disclosure and referrals to other healthcare providers, including treating doctors, physiotherapists, and other specialists or orthopaedic company representatives. This includes medical investigations, app registration and data collection to support your clinical care.

Name: (Please type your full name. By doing so, you agree that this constitutes your electronic signature.)

Patient Registration Form

New Patient Form

Patient Details

Medicare & Health Insurance

Allergies

HEART / CARDIAC CONDITIONS

MEDICATIONS - Anti-inflammatory (NSAIDs) &/or Disease Modifying Drugs

ALL CURRENT MEDICATIONS &/or SUPPLEMENTS

Please list ALL medications:(include aspirin, cortisone, steroids, anti-inflammatory, anticoagulants, herbal products and over-the-counter preparations, including the previously mentioned medications in this form )

PREVIOUS OPERATIONS

BODY PART(s) INJURED / AREA of CONCERN

Select the affected area

CONSENT

REFERRAL SOURCE

Returning Patient Form

Patient Details

Medicare & Health Insurance

Allergies

Conditions

BODY PART(s) INJURED / AREA of CONCERN

Select the affected area

ALL CURRENT MEDICATIONS &/or SUPPLEMENTS

Please list ALL medications:(include aspirin, cortisone, steroids, anti-inflammatory, anticoagulants, herbal products and over-the-counter preparations, including the previously mentioned medications in this form )

PREVIOUS OPERATIONS

CONSENT

CONTACT US

ORTHOPAEDIC SERVICES

Hip Conditions

Knee Conditions

Shoulder Conditions

Spine Conditions

Hand Conditions

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