New patient form

New Patient Form

Please fill the form below to become a new patient to Melbourne Spine Studio.

We aim to provide you with the best possible evidence-based treatment and personalised care. Please complete all sections and read the Personal & Health Information Consent section at the end of this form. Please contact reception if you have any questions or require assistance completing this form.

Patient Details

Patient Name(Required)

Title First Last

Preferred Name

Date of Birth(Required)

Australia is a gender-inclusive and multicultural society. We tailor appropriate care and encourage understanding and appreciation between people from different genders, nationalities, and cultural backgrounds. Knowing your background can help us provide healthcare that meets your individual needs.

Sex

Ethnicity

Aboriginal / Torres Strait Islander Origin:

Yes

Do you have any specific cultural requirements?

Do you speak a language other than English?

Yes

What language/s do you speak?

Do you require an interpreter?

Yes

Language Required

Address(Required)

Street Address Address Line 2 City State Postal Code

Mobile Number(Required)

Home Number

Work Number

Email(Required)

A copy of this completed form will be sent to this email address.

Occupation

Medicare Number(Required)

Position on card(Required)

Expiry(Required)

Private Health Fund

Member No.

Do you have any of the following?

Pension Card

DVA

Health Care / Concession

Type

Card Number

Expiry

Are you making a claim?

WorkCover Claim

TAC Claim

Claim Number

Date of Injury:

Case Manager’s Name

Insurer’s Name

Contact Number

Employer

Date of Injury

Referrer Details

Referrer

Referrer Contact Number

Referrer Email (if known)

Referrer Address

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

General Practitioner (if different from referrer)

Practice Name

Emergency Contact’s Name(Required)

Relationship(Required)

Phone Number(Required)

Patient Medications

Current Medications and Supplements (including dosages)(Required)

Medical History

(Check if you have any of the following.)

Diabetes

Heart Disease

High Blood Pressure

Blood Clot (Deep Venous Thrombosis (DVT) or Pulmonary Embolus (PE))

Lung Disease

Liver or Kidney Disease

Thyroid Disease

Pituitary Disease

Epilepsy

Asthma / Eczema / Hay Fever

Cancer (yourself)

Psychiatric Treatment

Autoimmune Disease

Other Conditions (E.g. Fibromyalgia)

Smoke / Alcohol / Drugs?

Other Medical History / Additional Comments

Main Symptom(s) / Complaint(s) For This Review

Spine Imaging Previously Performed (X-Ray, MRI, CT, Others)

Yes

Name of Radiology Practice(s) Imaging(s) Was/Were Performed:

Date(s) of Spine Imaging(s) Previously Performed

Previous Spine Injection(s)

Yes

Name of Radiology Practice(s) Injection(s) Was/Were Performed:

Date(s) of Spine Injection(s) Previously Performed

Family History and Genetic Conditions

Allergies / Intolerances (including symptoms)

Where does it hurt?

Please specify which part of your body, and on which side.

Pain Scale (0 being no pain, 10 being the worst pain)

Please rate the severity of your pain on the above scale.

Personal & Health Information Consent

We respect your privacy rights and take our privacy obligations seriously. We comply with the Australian Privacy Principles found under the Privacy Act 1988. Our Privacy Policy can be obtained from:

melbournespinestudio.com.au
Reception

You consent to Melbourne Spine Studio collecting your personal and health information by signing this form. Please read this information carefully, and sign where indicated below.

Melbourne Spine Studio collects information from you for the primary purpose of providing you with healthcare services. We require you to provide us with your personal and health information, including your complete medical history, so we may provide our services. We will also use the information you provide in the following ways:

Appropriately manage our practice, such as conducting audits and undertaking accreditation processes, managing billings and training staff;
Effectively communicate with third parties, including Medicare Australia, Private Health Insurers, government departments and other practitioners involved in your healthcare;
Data collected from consultations and surgeries will be used for research purposes. All information will be de-identified.

I have read the information above and understand why my data is collected and how it is used. I acknowledge that I am not obliged to provide any information requested but that failure to do so might compromise the quality of care.

Full Name

First Last

Date

MM slash DD slash YYYY

Patient Signature

Signed as (for patients under 18 years)

Parent

Guardian for

Name Relationship

How did you hear about us?

Would you rather a paper version?

Download, print, and fill in the new patient form, and bring it in when you come for your appointment.

Download Form

Patient Details

Referrer Details

Patient Medications

Personal & Health Information Consent

Would you rather a paper version?

Download, print, and fill in the new patient form, and bring it in when you come for your appointment.

We're here to help.
Contact us for expert advice and care.

Get in touch

Opening hours

Patient Details

Referrer Details

Patient Medications

Personal & Health Information Consent

Would you rather a paper version?

Download, print, and fill in the new patient form, and bring it in when you come for your appointment.

We're here to help. Contact us for expert advice and care.

Get in touch

Opening hours

We're here to help.
Contact us for expert advice and care.