Patient Registration


Please complete and sign this Patient Registration and Medical History form prior to attending your appointment.
This form is emailed to Specialist.Clinic directly and forms part of your medical record.

When attending, please bring the following to your appointment:

  *    Medicare Card
  *    Health Insurance Details
  *    General Practitioner Referral letter
  *    List of current medications
  *    3rd Party or Worker's Compensation claim approval/details if relevant
  *    All Xrays, scans and their reports
  *    Recent blood tests
  *    Details of all previous operations
  *    Assistive devices, splints, crutches, walking aids
  *    Comfortable loose fitting clothing to facilitate examination and maintain modesty
  *    Support person if needed to assist with mobility
  *    Interpreter if you have a language barrier

DEMOGRAPHICS

EMERGENCY CONTACT, NEXT OF KIN

3RD PARTY AND WORKER'S COMPENSATION

MEDICAL HISTORY

TERMS OF SERVICE

I agree to share the information on this questionnaire with Specialist.Clinic and understand this medical record will form part of the decision making process and help guide and manage my treatment.
I give my consent to have photographs/video/images taken if required, prior to, during and after surgery for the purpose of my medical records. I give permission for these photographs to be used for teaching and educational purposes. I give permission for these photographs to be shown to other patients. I understand that I will not be identified in these photographs.
Permission is given to release the Medical History to other members of the treating team, Insurance Company or Legal Team (where applicable). All details given on this information Sheet will be kept in strictest confidence. Doctor may use some of your details for the purpose of audit/or medical research.