Patient Information Form – The Orthopaedic Group

Patient Information

Patient Details
Patient Medicare Details
Medicare Details Parent / Guardian (if under 16 years of age)
Private Health Fund
Patient Pension Card Details
Department of Veterans Affairs
Emergency Contact / Next of Kin Details
Referral Details
General Practitioner (if different to referring doctor)

Privacy consent and AI consent

Privacy in Medical Practice
Consent for use of an Artificial Intelligence Note Taking Tool during your Consultation

Workers Compensation and MVA

Workers Compensation Injury
Motor Vehicle Accident Injury
Third Party Authority for Release of Information

Medical questionnaire

Medical Conditions
Imaging
Medical Questionnaire
Pain Issues
Inflammatory Arthritis
Blood Clots
Mental Health
Other
Medications
Allergies

Patient Details

Which surgeon are you seeing today:

Title: Dr / Mr / Master / Mrs / Ms / Miss / Other*

Surname:*

First Name:*

Middle Name:

Preferred Name:

Date of Birth:*

Street Address:*

Suburb:*

State:*

Postcode:*

Home Phone Number:

Mobile Phone Number:*

Are you happy to receive messages by SMS?*

Yes

Email*

Are you happy to receive correspondence by email?

Yes

Patient Medicare Details

Medicare Number:

Reference No. (Number in front of name):

Expiry Date:

Medicare Details Parent / Guardian (if under 16 years of age)

Parent / Guardian Name:

Parent / Guardian Date of Birth:

Medicare Number:

Reference No. (Number in front of name):

Expiry Date:

Date of Birth:

I provide authorisation for the Practitioner to claim the rebate amount of my consultation direct from Medicare, should my account remain unpaid.

Signed:*

Date:

Private Health Fund

Health Fund Name:

Membership Number:

Does your cover include Hospital Cover?:

Yes

Have you held your insurance for over 12 months:

Yes

Patient Pension Card Details:

Pension Card Number:

Pension Card Expiry Date:

Department of Veterans Affairs:

DVA Card Number:

Card Type:

Area of Body Covered by Card:

Emergency Contact / Next of Kin Details

Full Name:*

Relationship to you:*

Home Phone Number:

Mobile Phone Number:*

Email Address

Referral Details

Referring Doctor Name:

Clinic Name:

Suburb:

Referral Document

Max. file size: 80 MB.

General Practitioner (if different to referring doctor)

General Practitioner Name:

Clinic Name:

Suburb:

Privacy in Medical Practice

We require your consent to store in accordance with the Australian Privacy Act 1988 and collect personal information about you and to collect and use the information you provide in the following ways.

Record, processing and documenting of your consultation with a health practitioner using AI (Artificial Intelligence)
Administrative purposes in running our medical practice including communicating via SMS and email for the purpose of appointments and relating to your healthcare
Billing purposes including compliance with Medicare and Health Insurance Commission
Share with other healthcare professionals involved in your care and in the event of emergencies
We will ask for your consent if third parties such as insurance and legal requests
We will share information as required by law such as subpoenas

Consent for use of an Artificial Intelligence Note Taking Tool during your Consultation

Before proceeding with the appointment, patients are informed about an essential aspect of how consultations are documented. A note-taking tool is utilised to accurately and efficiently capture the details of discussions and the outcomes of consultations with the doctor. The AI tool ensures that the doctor can focus more on the conversation and less on manual note-taking, thereby enhancing the quality of care received. Patient consent is crucial for the use of this technology. Please be assured, information will be handled with the utmost care and privacy, and the AI's use is solely aimed at improving the healthcare experience.

I authorise the collection and disclosure of information to my GP or any health care provider or other institution involved in my care.

I consent to communication via SMS and email for purposes of appointments and relating to healthcare, this is not for marketing material.

I understand I can withdraw my consent at any time by contacting administration.

I agree to allow the doctor to use the AI note taking tool during the consultation.

Patient full name (please print):*

Signature*

Date:

Workers Compensation Injury

Is your surgery related to a workers compensation injury?

Yes

This field is hidden when viewing the form

Name of Employer:

Employer Address:

Employer Contact Name:

Employer Contact Phone Number:

Date of Injury:

Employer’s Insurance Company:

Claim Number:

Body Part Covered by Claim:

Should this be a new injury and you do not know these details, you will be asked to pay the consultation invoice and provided with a receipt to claim from your employer. Please inform the rooms when you have all of the above details and future invoices for the injury will be sent directly to the insurance company / employer. If your claim is not accepted by the employer/insurance company, you will be liable for any invoices raised during the course of your treatment.

Motor Vehicle Accident Injury

Date of Accident / Injury:

Claim Number:

Body Part Covered by Claim:

Should this be a new injury and you do not know these details, you will be asked to pay the consultation invoice and provided with a receipt to claim later. Please inform the rooms when you have all of the above details and future invoices for the injury will be sent directly to the insurance company. If your claim is not accepted by the insurance company, you will be liable for any invoices raised during the course of your treatment.

Third Party Authority for Release of Information

Third Party Authority Information Name

give permission you to forward confidential information regarding my injury, the treatment I have received and guidelines for return to work to my employer, insurance company and rehabilitation provider.

Signature

Date:

Witness Signature:

This field is hidden when viewing the form

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