Patient Registration

Name*

Prefix First Last

Date of birth

Age

Gender

Male
Female

Address

Street Address Suburb Post code

Mobile phone*

Home phone

Email*

Occupation

Next of kin:

Relationship to patient

Next of kin contact

Medicare number

Reference number next to your name

Pension card number

Health card number

Medical history:

Referral details

Referring Dr

Prefix First Last

Address

Street Address Suburb Post code

Usual GP

Prefix First Last

GP Address

Street Address Suburb Post code

Referring Physiotherapist

Prefix First Last

Physiotherapist Address

Street Address Suburb Post code

Health fund & Veteran's affairs

Private Health Fund

Membership number

Have you been a member for more than 12 months?

Yes
No

Veteran Affairs card number

Work Cover / TAC Claim Details

Date of injury

Claim number

Insurance company

Insurance contact name

Employer

Employer contact name

Employer phone

Employer Address

Street Address Suburb Post code

Privacy Statement

Privacy Statement Mr Hamish Curry respects your right to privacy and complies with the legislation relating to the collection, storage, use and disclosure of health information. Our comprehensive privacy policy is available on request.

Fees

Initial Consultation	Standard fee: $200
Review Consultation	Standard fee: $100
Second Opinion/Complex Consultation	Standard fee: $250

Cancellation Policy*

I have read and agreed to Mr Hamish Curry’s Cancellation Policy.

Yes

By signing this form I have had opportunity to review the privacy policy. I understand and accept the above privacy statement and billing procedures.

Signature*

Date*

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Referral details

Health fund & Veteran's affairs

Work Cover / TAC Claim Details

Privacy Statement

Fees

Coronavirus pandemic information