Patient details

Name*

First Last

Sex*

Date of birth*

Postal Address*

Street Address City/Suburb State/Territory ZIP / Postal Code Country

Phone

Mobile*

Email*

Occupation*

Next of kin name and relationship to you*

Next of kin contact number*

Referring doctor*

Usual GP*

Allied health provider name

Medicare number*

Medicare expiry*

Medicare reference number*

This is the numbers to the left of your name on the medicare card

Private health fund

Private health fund membership number

DVA number

DVA colour

White

Gold

Other

Please list the condition/s covered

Other (Please specify)

Aged pension card number

Aged pension card expiry

Are you under 16 years old?*

Yes

Person responsible for account

Date of birth

Medicare reference number

This is the numbers to the left of your name on the medicare card

Are you a workcover patient?*

Yes

Workcover claim number*

Workcover date of injury*

Workcover employer*

Workcover case manager:*

Name*

Phone*

Email*

Patient history

Reason for presentation*

Have you had X-rays of the region in the last 3 months*

Yes

Please provide radiology clinic details

Clinic Name*

Clinic address*

Are you taking any of the following medications*

Ozempic (semaglutide)

Trulicity (dulaglutide)

Mounjaro (tirzepatide)

None

Privacy Policy

As a health care provider in the private sector, the Sunshine Coast Orthopaedic Group is bound by the National Privacy Principals provided in the Privacy Act 1988. These govern how we collect, handle, use, distribute and store personal information collected from our patients at the clinic. Ordinarily we do not release the contents of your file without consent. When dealing with other health care professionals, in order to obtain accurate diagnosis or treatment options we will ask your full consent to disclose personal medical details. Please indicate below and sign your consent for details to be disclosed when necessary.

Give permission for details relating directly to my medical condition to be discussed, if necessary, with other health care professionals.*

I do

I do not

How did you hear about us?*

Google Search

Social Media

GP or Allied Health Practitioner

Word Of Mouth

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Education Seminar

Other

Other (Please specify)

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Phone

This field is for validation purposes and should be left unchanged.

ONLINE PATIENT REGISTRATION FORM

Patient details

Patient history

Privacy Policy

SURGICAL OPTIONS

NON SURGICAL

CUSTOMER SERVICES