Patient Information

Surgeon*

ADr Ritesh Dawra

BDr Charles Dick

CDr Kim Latendresse

DDr Jonathan Dick

EDr Vasudev Navalgund

FMr James Tunggal

Patient Details

Title*

First Name*

Initial

Surname*

Address

Street*

Suburb*

State*

Postcode*

Date of Birth*

Email*

Occupation*

Home Phone*

Include area code

Work Phone

Include area code

Mobile*

SMS Reminders

ACheck box if you do not wish to receive SMS reminders of your appointments

Next of Kin

Name

Relationship*

Home Phone*

Include area code

Work Phone

Include area code

Mobile*

Referring Doctor

Referring Doctor’s Name*

Date of Referral

Referring Doctor's Address*

Referring Doctor's Phone*

Include area code

Family Doctor’s Name (If different from above)

Family Doctor's Address*

Family Doctor's Phone*

Include area code

Health Insurance

Medicare Card No*

Write 0 if you do not have a Medicare Card

No. Left of Name*

Expiry Date*

Do You Have Private Health Insurance*

AYes

BNo

Name of Health Fund*

Membership Number*

No. Next to Name (If Applicable)

Date Joined*

Type of Coverage*

AHospital & Extras

BHospital Only

CExtras Only

Any Exclusions*

Do You Have a DVA Card*

AYes

BNo

DVA No*

Colour of Card*

Is This a Work Claim*

AYes

BNo

Date of Injury / Accident*

Date of Claim*

Claim Number*

Case Manager (If Known)

Phone (If Known)

Include area code

Insurance Company Name

Phone

Include area code

Address

Company / Employer’s Name*

Phone*

Include area code

Address*

YOUR PRIVACY, OUR CONCERN | CONSENT TO USE YOUR PERSONAL INFORMATION

Orthopaedics Queensland complies with the Commonwealth Privacy Act and all other state and territory legislative requirements in relation to the management of personal information. We collect information that is necessary for the provision of your health care. Personal information obtained from you in your consultation may be used to provide information to various health services involved in supporting your health care management (e.g. pathology, radiology, hospitals or other specialists).

AI have read and understood Orthopaedics Queensland’s Privacy Policy and understand my rights and responsibilities.

Declaration

I hereby consent to my personal information being released as and when required.*

Name of Patient / Guardian / POA

Signature of Patient / Guardian / POA*

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Date*

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