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

Surname *

Title *

MrMrsMissMs

Given Names *

Date of Birth *

Address *

Street address

City

State

Postcode

Mobile Phone

Work Phone

Home Phone

Email

Family Doctor

Family Doctor Name *

Family Doctor Address (Include Suburb and Postcode) *

Doctor's Phone *

Doctor's Email *

Next of Kin

Name of First Contact *

Relationship (to First Contact)

Phone Number *

Name of Second Contact

Relationship (to Second Contact)

Phone Number of Second Contact

INSURANCE DETAILS

Medicare Card No.

Medicare Reference No.

IRN

Private Health Insurance

YesNo

Health Fund

Membership No.

Policy Name

UPIUniversal Patient Identification number

Hospital Cover

YesNo

DVA (Department of Veteran's Affairs)*Fill up if applicable

DVA Card Condition (indicate Gold, White or Orange)

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

Patient/ Guardian Signature *

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Today's Date *

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PATIENT DETAILS

Family Doctor

Next of Kin

INSURANCE DETAILS

SIGNATURE

GENERAL MEDICAL HISTORY

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