New Patient Registration Form

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NEW PATIENT REGISTRATION FORM

Dr Joanna Lenaghan

Foot and Ankle Orthopaedic Surgeon

REQUEST AN APPOINTMENT

Title

First name

Last name

Preferred Name

Date Of Birth * required

Address

Suburb

State

Postcode

Contact

Mobile No.

Work No.

Home No.

Email

Dte of Appointment

Surgeon

Occupation

Energency Contact

Name

Contact Number

Relationship

Referring Doctor

Name

Contact Number

Address

Regular GP

Yes

As above

Name

Contact Number

Address

Account Details

Medicare Number

Ref Number Next to Name

Veterans Affairs No (if applicable )

Gold Card

Yes

No

Private Health Insurance*

Yes

No

Is your appointment related to a TAC or WorkCover Accident?

Yes

No

Medical History

DVT *

Yes

No

PE (Pulmonary Embolism) *

Yes

No

Blood Clots *

Yes

No

Are you a Diabetic *

Yes

No

Insulin Dependent

Yes

No

Are you taking any regular medication *

Yes

No

If yes, please list

YesI accept the fees, charges and privacy policy

How did you find out about Melbourne Hip and Knee? *

GP

Internet Search

Family/Friend Recommendation

Social Media

Physio

Public Hospital

Other

CONSULTATION FEES Payable on day of consultation

Private Fees:

104 (initial consultation) = $230.00
105 (review) = $130.00

Note:

WorkCover or TAC patients

• Must provide Claim Number on day of Consultation
• You will also pay a minimal out of pocket for this consultation no more than $35
• This MUST be paid on the day of Consultation
• If you present without a Claim Number you will be required to pay consultation charges in full and then claim back your rebate from either WorkCover or TAC.

PRIVACY STATEMENT

This practice is committed to protecting your privacy. Health information obtained during the consultation and treatment is collected to ensure a high quality of care. This information may be disclosed to other health professionals involved in your care. However, this information may be disclosed to other organizations where required by law. This information may also be disclosed to a debt - collecting agency if payment has not been received by three months from the date of service.

Thanks for submitting!

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