Test Form – The Orthopaedic Group

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 *

City *

State/Province *

ZIP / Postal Code *

Home Phone Number

Mobile Phone Number *

Are you happy to receive messages by SMS? *YesNo

Email *

Are you happy to receive correspondence by email? *YesNo

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

Signature

Date

Private Health Fund

Health Fund Name

Membership Number

Does your cover include Hospital Cover?:YesNo

Have you held your insurance for over 12 months:YesNo

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

No file chosen

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.

Consent for use of clinical and operative images

Images and/or video of you may be taken by the surgeon in clinic, pre-operatively, intra-operatively or post-operatively. These may be used for the purposes of diagnosis, monitoring and delivery of healthcare, research, publication to other health professionals and/or publication for websites or promotion in compliance with Australian Privacy Act and the Australian Privacy Principles and all personal identifiers removed. Images will be stored securely in your patient record and all other existing images destroyed upon upload to your record.

Please indicate below the uses you consent to *Diagnosis, monitoring and delivery of my healthcareResearch purposesEducation to other healthcare professionals onlyPublication on websites and/or publications

By signing below, you provide consent for the collection and use of images as outlined above. This consent can be withdrawn at any time by contact the rooms in writing (info@ogwa.com.au).

Patient full name (please print) *

Signature *

Date *

Workers Compensation Injury

Is your surgery related to a workers compensation injury? *YesNo

Name of Employer

Email 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

Is your surgery related to a motor vehicle accident Injury? *YesNo

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

IPatient/guardian full 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 *

Medical Questionnaire

Occupation

Weight (in kg)

Height (in cm)

Previous Surgery: (please list the nature of surgery and date of surgery)

Do you smokeYesNo

Do you vapeYesNo

Do you drink alcoholYesNo

Imaging

Have you had previous imaging of the body part you are seeing the surgeon about?YesNo

Other

Medical Conditions

Do you have any of the following medical conditions?

Diabetes Type IYesNo

Diabetes Type IIYesNo

Treated withDietTabletsInsulin

Last HbA1c Percentage

Date

Pain Issues

Chronic painYesNo

Complex Regional Pain Syndrome (CRPS)YesNo

FibromyalgiaYesNo

Inflammatory Arthritis

Rheumatoid ArthritisYesNo

Ankylosing SpondylitisYesNo

Psoriatic ArthritisYesNo

Other

Blood Clots

Deep Vein Thrombosis / DVTYesNo

Year(s)

Pulmonary Embolus / PEYesNo

Year(s)

Mental Health

AnxietyYesNo

DepressionYesNo

Other

Osteoporosis / osteopaenia (reduced bone density)YesNo

Heart attackYesNo

Heart disease (ie. Coronary artery disease / stent / CABG etc.)YesNo

Stroke (CVA / TIA)YesNo

Neurological condition

Lung diseaseYesNo

Sleep apnoeaYesNo

AsthmaYesNo

COPDYesNo

CPAP UseYesNo

Liver disease / failureYesNo

Peripheral NeuropathyYesNo

HepatitisYesNo

Type

HIVYesNo

CancerYesNo

Type

Medications

Are you taking any GLP-1 agonists (ie. Weight-loss or diabetes medication)?

Other

Are you on any blood thinning medications?

AspirinYesNo

Warfarin (coumadin)YesNo

Clopidogrel (Plavix)YesNo

Apixaban (Eliquis)YesNo

Clexane/Heparin InjectionsYesNo

Other

Do you take immune-suppressing drugs (ie. Steroids or rheumatoid drugs)?YesNo

List

Are you take any other regular medications or supplements?YesNo

List

Allergies

List

Patient Name *

Signature

Date

New Patient Form

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)