New 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

No

If Yes, Where were your investigations taken?

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

No

Which Emergency hospital?

St John of God

Epworth

Geelong Hospital

OtherOther

Are you a minor? *

Yes

No

Parent or guardian details

Parent or guardian name

Home phone

Mobile phone

Work phone

Email

Are you a pension/concession card holder? *

Yes

No

EPC / GP Management Plan? *

Yes

No

If yes please give Medicare details *

Workcover claim? *

Yes

No

Workcover details

Workcover Claim Number

Insurer

Employer

Employer Contact Person

Employer Phone

Employer Email

TAC claim? *

Yes

No

TAC 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 Card

Are 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

No

Do 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 $10.00

TERMS 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 line 1

Address line 2

City

State

Post code

How will you be paying today? *

Agreement and Consent

Consent *

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 *