Patient Registration Form - Panorama Orthopaedics

Personal Details

Name*

First Last

Phone - Home

Phone - Mobile*

Email*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Extra Notes

Insurance Details

Medicare No:

Ref No:

Expiry Date

Private Heath Insurance:

Yes
No

Fund Name:

Fund No:

Dept. Veterans Affairs Card No:

White
Gold

Expiry Date:

Concession Card

Aged or Disability Pension No

Expiry Date:

Health Care Card No

Expiry Date:

General Practitioner's Details

Name

Practice name:

Address

Referring Doctor

Doctor

GP
Specialist
Other

Name of Referrer

Next of Kin Details

Name

Relationship to you

Contact Number

Are you happy for Dr Host (or staff) to call your Next of Kin after operation?

Yes
No

Medical Questionnaire

Please list all current medications including herbal or vitamin preparations:

Allergies

Do you have any know allergies?

Yes
No

If Yes, please list:

Multidisciplinary Meetings

I consent to my case being discussed in Multidisciplinary Meetings as deemed appropriate by Dr Host:

Yes
No

Photography Consent:

Video and still images are occasionally taken during operative procedures. These become a part of your confidential medical records. We also would like to ask you for permission to use these photos for educational purposes in addition to their use as part of your medical care. All images used for purposes other than the medical records are de-identified. Names are not used and as far as possible identifying factors are masked.

Do you consent to these images being used for the purpose of (1) teaching, (2) publication in medical journals, (3) educating patients?

Yes
No

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Name

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