REGISTRATION FORM Please complete the form and bring it to your appointment with Dr B. Martin or email to Miss Ms. Birth date: Age: Patient’s First name: Last name: / / Home Phone Mobile phone no: Opt out of SMS □ appointment reminders Email: Street Address: ( ) P.O. Box: Suburb: State: Post Code: Occupation: Treatment area: eg / Left Height: Weight: Toe/ Foot/ Ankle Next of Kin: Relationship: Phone Referring Doctor: (name, address + Ph) General Practitioner: (name, address + Ph) Physiotherapist: (name, address + Ph) Medicare No: Ref No: Exp date: Private Health Insurance No: Pension Type No: Veterans No: Are you making a claim for Compensation? Yes / No Date of Injury: Workers Compensation CTP Personal Injury Public Sports Insurance □ □ □ □ □ Claim Liability Claim Number: Insurer: Case Manager Name Phone Contact Insurers postal address: Insurers email: Declaration: I give permission for correspondence to be sent to my referring doctor, general practitioner, physiotherapist and insurance company where appropriate. I undertake to pay all fees owing to my Surgeon, including in the event that liability is denied or any outstanding accounts that have not been paid in full by my insurer. I also understand that any outstanding monies requiring debt recovery will incur Debt Recovery fees and I will also be responsible for any legal cost incurred Patient/Guardian signature Date Name (please print):
REGISTRATION FORM Please complete the form and bring it to your appointment with Dr B. Martin or email to Miss Ms. Patient’s First name: Last name: Birth date: / / Age: Home Phone Mobile phone no: □ Opt out of SMS appointment reminders Email: Street Address: ( ) P.O. Box: Suburb: State: Post Code: Occupation: Treatment area: eg / Left Toe/ Foot/ Ankle Height: Weight: Next of Kin: Relationship: Phone Referring Doctor: (name, address + Ph) General Practitioner: (name, address + Ph) Physiotherapist: (name, address + Ph) Medicare No: Ref No: Exp date: Private Health Insurance No: Pension Type No: Veterans No: Are you making a claim for Compensation? Yes / No Date of Injury: □ Workers Compensation □ CTP □ Personal Injury Claim □ Public Liability □ Sports Insurance Claim Number: Insurer: Case Manager Name Phone Contact Insurers postal address: Insurers email: Declaration: I give permission for correspondence to be sent to my referring doctor, general practitioner, physiotherapist and insurance company where appropriate. I undertake to pay all fees owing to my Surgeon, including in the event that liability is denied or any outstanding accounts that have not been paid in full by my insurer. I also understand that any outstanding monies requiring debt recovery will incur Debt Recovery fees and I will also be responsible for any legal cost incurred Patient/Guardian signature Date Name (please print):