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New Patient Registration

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* required field

1 Already have an appointment?

Do you already have an appointment with us? *

Please book an appointment before filling in this form. You can contact us here for more information

2 Personal Information

Residential Address: *

Billing Address - Same as Residential? *     

3 Referring Doctor Information

4 Health Fund

Do you have private health insurance?

5 Workcover Claim

Is this a WorkCover claim?
Accepted claim:

6 TAC Claim

Is this a TAC claim?
Has excess been paid:
Were police notified:

7 Medical History

Please answer all questions.
Have you ever had any of the following: *
High blood pressure
Heart trouble
Insertion of pacemaker
Kidney disease
Diabetes
Bleeding tendency
Rheumatic fever
Blood disease
Hepatitis
Lung disease
Blood clots / throm
Epilepsy
Asthma
Are you allergic to any medicine or tapes: *
Have you ever been given cortisone tablets/injections: *
Females - Are you pregnant?
Have you been tested for HIV antigen: *
If so:
Do you smoke: *

8 Authorisation

PATIENTS PLEASE NOTE

Patients are advised that The Melbourne Orthopaedic Group does bill Medicare direct for Patient Accounts. All patients will receive an Account for professional services provided.

Accounts are itemised at the AMA recommended fee level. The AMA recommends a fee schedule based on what is fair and reasonable, but patients are reminded that these are beyond the standard rebate provided by Medicare. Other arrangements can be discussed with your Doctor.

WorkCover and T.A.C patients must provide correct details of the organisation accepting liability for payment of services including their employer, insurance company and claim number before treatment is undertaken.

Therapy services are not rebateable by MediCare, but are rebateable by Private Health Funds.

You will be given your account after your consultation at which time settlement would be appreciated. Mastercard and VISA credit facilities are available.

The terms of the contract are settlement of all consulation accounts on the same day and surgical accounts within 30 days. Please note if your attendance is for a second opinion you should have all correspondence and investigations available from other clinicians. There MAY be an increased charge for second opinions.

I agree to my medical information to be emailed electronically to any of my treating medical practitioners. I agree to the Terms & Conditions