Contact Form

Patient Registration Form

This is an online form for patients to register for surgery.

All details are secure and treated confidentially according to Privacy Law.

Name

Prefix

First

Last

Preferred Name

Email address*

Contact Numbers

Mobile*

Home Phone

Work Phone

Address

Address Line 1*

Address Line 2

Suburb/City*

Postal Code/ZIP*

State*

Date of Birth*

Occupation*

Dominant Hand*

Left

Right

Next of Kin Details

Full Name*

Phone*

Relationship*

Medicare Details

Medicare

Ref. No

Pension/HCC Details

Pension/HCC Number

Expiry

Health Fund Details

Health Fund Name

Membership Number

Member for more than 12 months?

Yes

Veterans Affairs Card

Veterans Affairs Number

Card Colour

GP Details

Regular GP

GP Clinic

Physiotherapist Details

Treating Physiotherapist Name

Physiotherapy Clinic Name

Other Allied Health Professionals (Osteo, Chiro, etc)

Other Health Professional Name

Clinic Name

Others

Are you a Workcover or TAC patient?*

Yes

Workcover/TAC Details

Insurance Company

Case Manager

Claim Number

Phone

Employer

Employer Address

Address Line 1

Address Line 2

Suburb/City

Postal Code/ZIP

State

TAC Details

Claim Number

Date of Accident

*PLEASE NOTE: If you are a Workcover or TAC patient, you must provide your claim number and all relevant documents to confirm your claim acceptance. *All consultations fees must be paid in full on the day, and we will provide you with a receipt for you to claim reimbursement from Workcover or TAC. If you require any paperwork to be completed/signed by the surgeon (including certificates of capacity) this needs to be completed during your consultation.

I Understand

I understand and consent for Melbourne Arm Clinic to collect and distribute my personal/medical information to/f rom other health providers if required, for the purpose of my treatment and surgical planning. My personal information may be used for billing purposes i.e. Medicare, Private health insurance, Workcover or TAC (if applicable). I understand I am not obliged to provide any information requested of me, but failure on my part may compromise the quality of treatment provided.*

I understand

This field should be left blank