New Patient Registration

Do you already have an appointment with us?*
- Yes
- No
Which Surgeon?*
Please book an appointment before filling in this form. You can contact us here for more information.

Referring Doctor
Referring Doctor Number
Referring Doctor Address
Is your Referring Doctor your Family doctor?
- Yes
- No
Family Doctor - if not referring doctor
Family Doctor Number
Family Doctor Address

Do you have private health insurance?*
- Yes
- No
Fund Name
Membership Number

Is this a WorkCover claim?*
- Yes
- No
Employer Name
Employer Address
Employer Phone
Insurance Company
Case Manager Name
Claim Number
Date of Injury
Date Format: DD slash MM slash YYYY
Claim Accepted?
- Yes
- No

Is this a TAC Claim?*
- Yes
- No
Place of injury
Claim Number
Case Manager Name
Date of Injury
Date Format: DD slash MM slash YYYY
Has excess been paid:
- Yes
- No
Were police notified:
- Yes
- No

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

Step 1 of 8 - Already have an appointment?

Residential Address*

Please take a moment to read the following:

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New Patient Registration

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