New Patients Form

Section 1: Personal Details

MrMrsMsMissMasterDr

First Name

Surname Name

Address

Suburb

Postcode

Phone

Email

Date of Birth

Parents Full Name (if under 18)

Do you have health insurance extras?
YesNo

If yes, which fund?

Do you have a Centrelink Pension or Health Care Card?
YesNo

CRN Number

Expiry Date

Current GP / Clinic Name

Did they refer you?
YesNo

How did you hear about us?
Friend / FamilyWebsiteInternet (eg Google)Other

Next of Kin

First Name

Surname Name

Mobile Number

Home Number

Work Number

Relationship to you

Is your visit covered by any of the following?

Department of Veterans Affairs:
YesNo

If Yes, is your card Gold or White
GoldWhite

If White, list condition

Travel Accident Commission (TAC)
Yes (Please complete Section 2)No

Workcover Authority
Yes (Please complete Section 3)No

Section 2: Travel Accident Commission (TAC)

Date of Accident

Claim Number

Case Manager Name

Contact Number

Section 3: WorkCover Authority / WorkSafe Victoria

Date of injury

Claim Number

Employer / Business Name

Address

Suburb

Postcode

Contact Name

Contact Number

Email

Name of Insurer (if known)

Case Manager Name (if known)

Contact No. / Email

I acknowledge that it is my individual responsibility to pay for appointment fees on the day of appointment, or for any outstanding balances for services previously provided. This will also apply for Medicare and insurance purposes (eg WorkCover, TAC, etc) should my claim be unsuccessful.