Ballarat OSM Patient Registration Form

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* 2. Patient details

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* 3. Are you of Aboriginal and/or Torres Straight Islander origin? 

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* 4. Date of birth:

Date

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* 5. Next of Kin Details

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* 6. If parent of child under 16 - please provide your D.O.B for Medicare claiming:

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* 7. If parent of child under 16 - please also provide your number on the Medicare card:

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* 8. Who is your referring Doctor?

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* 9. At which clinic did you see this Doctor?

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* 10. Usual Doctor, if different to the one named above:

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* 11. Are you seeing a Specialist or Physician?

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* 12. If so, who are you seeing?

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* 13. Are you seeing a Physiotherapist?

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* 14. If so, who are you seeing?

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* 15. Do you have allergies?

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* 16. If yes, please specify:

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* 17. Are you a diabetic?

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* 18. If so, are you Insulin dependent?

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* 20. Your height:

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* 21. Your weight:

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* 22. Medicare number:

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* 23. Medicare reference number (next to name)

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* 24. Medicare card expiry date

Date

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* 26. Name of Private Health fund? 

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* 27. Private Health membership number: 

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* 28. If you have Veteran's affairs, please provide card number:

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* 30. If you have a Pension/Health Care Card - please provide details:

PRIVACY STATEMENT

Ballarat OSM Pty Ltd, their partners and staff are committed to the protection of your privacy. We require you to provide your personal details and full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. This means that we will use the information you provide in the following ways:

  • Administrative purposes in running our medical practice
  • Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
  • Disclosure to others involved in your health care, through treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following referrals.
  • Disclosure for research and quality assurance activities to improve individual and community health care and practice management. (Individuals are not identified in these circumstances.)
  • X-rays and de-identified clinical photographs may be used for teaching purposes.

I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on the handling of patient information.

I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me. 

I understand that if my information is to be used for any other purposes other than that set out above, my further consent will be obtained.

I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I notify this practice of.

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* 31. I have read the Privacy Statement and consent to the conditions:
(Please write name of person providing consent)

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* 32. Date completed:

Date
ACCOUNT INFORMATION
  • Consultation costs must be paid on the day.
  • Costs incurred in relation to the provision or fitting of any equipment, i.e.. a Vacoped cast or boot, are payable on the day. Reimbursement may be sought from your Health Insurance provider (through extras cover), Department of Veteran's Affairs, Employer, Work cover Insurer or TAC.
  • Extras costs for surgery must be paid prior to the date of surgery.
  • Any account that remains unpaid for a 90 day period will result in the denial of any future appointment being made within the practice.
  • Any costs involved in recovering outstanding accounts will be the responsibility of the patient. 

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* 33. Why did you choose to come to Ballarat OSM?

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