Patient Registration Form

Personal Details:

Other

Date of Birth

First Name (as it appears on you Medicare Card)

Surname

Street Address

Suburb

Post Code

Postal Address (if different from address above)

Email Address

Contact Phone No (mobile preferred)

Medicare Card No

Reference No

Expiry Date

Are you covered by the Department of Veterans Affairs?

Yes No

If yes, what is your card number

Private Health Insurance Company

Membership No

Pension/Health Care Card No (please select)

Card Number

Expiry Date

Next of Kin or Emergency Contact Person:

Name and Relationship

Contact Phone No

Is your visit today related to a Workcover or TAC Claim?

Workcover TAC Claim Not Covered

If it is please provide:

Claim Number

Insurance Company handling Claim (Workcover Only)

Please note you will need to pay for your consultation even if you have a Workcover or TAC claim number, however we still require these detailss for any future surgical procedures that may be required in your treatment pathway.

Referring Doctor & Other Health Provider Information:

Who referred you for your consultation

Is this doctor you GP?

Yes No

If your GP did not refer you today who is your GP (name and address):

Name of your GP

Address of your GP

Do you see an allied health professional?

If you do, please provide their name and address: (we will ensure that relevant correspondence is sent to them)

If Other, please specify

Please note:

All consultation fees are to be settled at the conclusion today (except those covered by the Department of Veterans Affairs). We are able to claim the Medicare Rebate electronically on your behalf today once the account has been paid. Workcover and TAC patients can claim a portion of their account from the appropiate third-party claim agent.

GP referrals are valid for a period of 12 months from the date of consultation. Referrals from other specialist or Emergency Department Doctors are only valid for 3 months from the date of consultation.

By completing this patient registration form we understand that you have acknowledged and understood our Privacy Policy (click here to view VOA Medical Practice Privacy Policy)

To Register

Complete & Return Our Online Form

To Register Your Details, Please Complete & Submit Our Online Form

Contact VOA to book your appointment with our orthopaedic doctors.

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To Register

Complete & Return Our Online Form

To Register Your Details, Please Complete & Submit Our Online Form