New Patient Registration

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This field is for validation purposes and should be left unchanged.

Do you already have an appointment with us?*

Yes

Which Surgeon?*

Please book an appointment before filling in this form. You can contact us here for more information.

Title*

First Name*

Last Name*

Residential Address*

Street Address*

Suburb*

State*

Postcode*

Billing Address – Same as Residential?*

Yes

Billing Address*

Suburb*

State*

Postcode*

Home Phone

Business Phone

Email Address*

Mobile

Occupation

Marital Status

Date Of Birth*

Responsibility for account – Account must be settled following consult:*

Self

Parent

DVA

TAC

Workers Compensation

Emergency Contact Name

Emergency Contact Number

Emergency Contact Relationship

Do you have a medicare card?*

Yes

Medicare Number

Reference Number

Expiry Month

Expiry Year

Are you a Veteran?*

Yes

Vetran Affairs Number

Card Colour*

Referring Doctor

Referring Doctor Number

Referring Doctor Address

Is your Referring Doctor your Family doctor?

Yes

Family Doctor – if not referring doctor

Family Doctor Number

Family Doctor Address

Do you have private health insurance?*

Yes

Fund Name

Membership Number

Is this a WorkCover claim?*

Yes

Employer Name

Employer Phone

Employer Address

Insurance Company

Case Manager Name

Claim Number

Date of Injury

Claim Accepted?

Yes

Is this a TAC Claim?*

Yes

Place of injury

Case Manager Name

Claim Number

Date of Injury

Has excess been paid:

Yes

Were police notified:

Yes

Have you ever had any of the following:*

High blood pressure

Heart trouble

Insertion of pacemaker

Kidney disease

Diabetes

Bleeding tendency

Rheumatic fever

Blood disease

Hepatitis

Lung disease

Blood clots / throm

Epilepsy

Asthma

None of these

Are you allergic to any medicine or tapes*

Yes

Details

Have you ever been given cortisone tablets/injections?*

Yes

Have you suffered any serious illness in the past?

Have you had any operations before?

Current Medications

Females – are you pregnant?

Yes

Possibly

Are you a smoker?*

Yes

How many per day?

Please take a moment to read the following:

Patients are advised that The Melbourne Orthopaedic Group does bill Medicare direct for Patient Accounts. All patients will receive an Account for professional services provided.

Accounts are itemised at the AMA recommended fee level. The AMA recommends a fee schedule based on what is fair and reasonable, but patients are reminded that these are beyond the standard rebate provided by Medicare. Other arrangements can be discussed with your Doctor.

WorkCover and T.A.C patients must provide correct details of the organisation accepting liability for payment of services including their employer, insurance company and claim number before treatment is undertaken.

Therapy services are not rebateable by MediCare, but are rebateable by Private Health Funds.

You will be given your account after your consultation at which time settlement would be appreciated. Mastercard and VISA credit facilities are available.

The terms of the contract are settlement of all consulation accounts on the same day and surgical accounts within 30 days. Please note if your attendance is for a second opinion you should have all correspondence and investigations available from other clinicians. There MAY be an increased charge for second opinions.

I agree to my medical information to be emailed electronically to any of my treating medical practitioners.

I agree to the Terms & Conditions*

Yes, I Agree

No, I do not Agree

MOG Patient Registration

Residential Address*

Please take a moment to read the following:

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