Private Patient Registration Form

Mr. W.H.B.Edwards
M.B., B.S, Dip. Anat., M.S., F.R.A.C.S., F.A Orth. A.
Orthopaedic Foot & Ankle Surgeon

W.Edwards Pty. Ltd. A.C.N. 082 121 284

PATIENT DETAILS

Family Doctor

Next of Kin

INSURANCE DETAILS

Universal Patient Identification number
*Fill up if applicable

ALL ORTHOPAEDIC MANAGEMENT IS CONDUCTED THROUGH THE PRIVATE HEALTH SYSTEM
Privacy Lesiglation: 
 This legislation requires we inform you that:

  • Your records and personal infromation are kept strictly confidential.

  • Information about your medical condition will be communicated to other medical and allied health practioners where necessary.

  • You may request a copy of your medical history (a fee will be charged).

  • In some circumstances we may be compelled by law to reveal details of your medical record.

  • Your records and information may be used for clinical / research.

CHARGES:

A consultation fee of $220.00 is to be paid on the day of consultation for inital and review appointments.

This will incure an out of pocket cost. 

Operative Fees are generally based on a Private Schedule of fees and are payable within 48 hours after Surgery. 

I understand that medical reports and medicolegal work or time spent as an expert witness are charged according to Mr. Edwards private schedule of fees: I accept this and understand that prior payment is required for this work. 

30% loading will be added to accounts outstanding over 60 days.

SIGNATURE

Draw signature|Type signatureClear

Please continue onto the next page.


GENERAL MEDICAL HISTORY


If so please provide details to reception