New Patient RegistrationNew Patient Registration Your details Title * First name * Surname * Preferred name (if different from above) Date of birth (DD/MM/YYYY) * Home phone Work phone Mobile phone Email Address (PLEASE INCLUDE SUBURB) * Occupation Presenting problem: * Have you had any investigations? (X-Ray, Ultrasound, MRI) * Yes NoIf Yes, Where were your investigations taken? Lake Imaging BMI Radius Epworth Imaging RIS TLC Imaging OtherOther Date of injury Date of surgery Name of surgeon Referring doctor GP GP clinic/address (if you do not have a GP please enter N/A) * Did you attend Emergency? * Yes NoWhich Emergency hospital? St John of God Epworth Geelong Hospital OtherOtherAre you a minor? * Yes NoParent or guardian details Parent or guardian name Home phone Mobile phone Work phone Email Are you a pension/concession card holder? * Yes NoEPC / GP Management Plan? * Yes No If yes please give Medicare details * Workcover claim? * Yes NoWorkcover details Workcover Claim Number Insurer Employer Employer Contact Person Employer Phone Employer Email TAC claim? * Yes NoTAC details TAC Claim Number Date of Injury * Private health insurance? * Yes No Fund * Membership number Ref Department of Veteran Affairs * Yes No DVA Number * DVA Card * Gold Card White CardAre you allergic to: * Tapes Massage creams* Other (please specify)Other (please specify) No Allergies*The main ingredients of the massage cream we use are: Arnica montana, Hypericum perforatum (St John’s Wort) Calendula officinalis and Melaleuca alternifolia (Tea Tree Oil)Do you have a pacemaker? * Yes NoDo you have a history of fainting? * Yes No Do you have any other health concerns you would like your therapist to know about? Please discuss any concerns with your therapist before commencing treatment. How did you hear about Geelong Hand Therapy Please note: Payment is expected at the time of service.Non-payment of accounts will incur an additional fee of $10.00TERMS AND CONDITIONS: 1. I agree to pay at the time of consultation unless an alternative arrangement has been made PRIOR to my appointment. 2. If payment is not received at the time of service, I understand a $5 administration fee may apply. 3. Outstanding accounts must be paid within 7 days, otherwise additional account processing fees may be charged. 4. Cheques can be made payable to Geelong Hand Therapy. 5. Credit card payments over the phone are accepted. 6. Medicare DOES NOT cover Occupational Therapy unless you have an Enhanced Primary Care (EPC) plan from your GP.Details of person responsible for payment of our invoices As above Different person Name * Phone * Address Address Address line 1 Address line 1 Address line 2 Address line 2 City City State State Post code Post codeHow will you be paying today? * Cash Cheque Credit Card EFTPOS OtherOtherAgreement and ConsentConsent * I understand the above terms and agree to abide by them. I also give permission for my / my child’s therapist to access and view any images ie X-rays, ultrasound, MRI investigations related to my / my child’s injury or condition, and to discuss my / my child’s treatment with my / my child’s referring G.P or Surgeon Patient / Parent / Guardian's name * Signature Clear Date * If you are human, leave this field blank. Submit