AAPSM

Sports Medicine Australia

Brunswick and Sandringham Foot Clinic - New Patient Registration Form


Brunswick Foot Clinic - New Patient Registration Form
 
Brunswick Foot Clinic | New Patient Registration Form

NEW PATIENTS please fill in and submit the form below. *Fields in bold are required fields.

Mr Mrs  Ms        
First name*   Middle name/s  
Last name        
Preferred name   Date of birth   / /
Street Address*   Occupation  
Suburb*   Postcode*  
Contact Details            
Home Phone*
     Mobile  
Work Phone     Email  
My preferred method of contact          
(PATIENT NUMBER)-(MEDICARE NUMBER)-(VALID UNTIL)
Medicare   - - /
 
(PATIENT NUMBER)-(MEMBERSHIP NUMBER)
Private Health   - Private Health Insurance Company  
           
 
Veteran's Affairs Card :   Gold White Patient Number: Card Number:
 
   
General Practitioner's (Doctor's) Name in Full    
Doctor's Address   Doctor's Phone  
 
 
How did you find out about us?
If you selected Other Patient or Health Practitioner, please give their name. If you selected Other, please give details.
 
 

Past Medical History
For the following four questions, if you have nothing to enter please simply type 'None'.

Please list any MEDICAL CONDITIONS that you think may affect your foot health (eg. diabetes)*
Please list any ALLERGIES, Sensitivities & Dietary Restrictions (eg. Band-Aid - blistering, Penicillin - skin rash)*
Please list any SURGICAL PROCEDURES that you think may affect your foot health (eg. artery bypass 1998)*
Please list any MEDICATION you take, amount & frequency of dosage (eg. Aspirin 300mg 1 tablet each morning) *
Body Weight (kilograms)*  Sporting Activities (e.g. Walking, yoga etc)
Do you wear orthotics or arch supports?* Yes   No
If so, are they Custom Made,or Pre-Formed
Briefly describe the pain you have and how long you have had it / or why you have come to see a podiatrist today:
Have you received any prior treatment for this problem?*  
Yes No 		 If so what, where and when?

Desired outcome of your visit.

If this is WorkSafe / TAC / ComCare related visit, please provide details below including date of injury, claim number, employer and insurance company.

If your General Practitioner has issued you with a Medicare Plus Care Plan, please be sure to bring your paperwork to your appointment.
We respect your privacy and all information collected is stored securely and accessed only by our staff. In order to provide a high and comprehensive standard of podiatry care there may be times when we communicate with your General Practitioner or your Allied Healthcare Practitioner. Please note payment of your account is required on the day of treatment. Unpaid accounts may incur administration charges. Medicare Plus patients agree to accept responsibility for their account when claiming their rebate from Medicare.

I have read the privacy information and I consent to collection and dissemination of information as described. I understand that provision of my medical history is necessary to provide me with effective, safe and efficient Podiatric care. I have answered all questions to the best of my knowledge. I agree to notify the Podiatrist of any change in my health.

Verification Code:  

 

Please click SUBMIT or PRINT out the completed form and bring it with you to your appointment
     

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