First Visit

When you come for your appointment please remember to obtain and bring the following:

Referral letter from GP, family physician or other doctor
Medicare card, DVA card, pension card
Have your Private Hospital Insurance information with you
Any other relevant information

In order to save time, we encourage you to fill out your patient details online prior to your appointment

PATIENT DETAILS

Title

First Name

Middle Name

Surname

DOB

Address

Suburb

Postcode

Phone-Home

Phone-Work

Phone-Mobile

Your Email

Medicare Number

Reference Number

Expiry

Private Health Fund

Membership No

DEPARTMENT OF VETERANS' AFFAIRS

Card No

Card Type

EMERGENCY CONTACT/ NEXT OF KIN DETAILS

Next of Kin

Relationship

Phone

REFERRAL DETAILS

Referring Doctor

Practice

WORKERS COMPENSATION

Employer

Address

Suburb

Postcode

Contact Name

Phone Number

Insurance Company Name

Claim-Number

Date of Injury

Contact-Name

Contact-Number

MOTOR VEHICLE CLAIM

Claim Number

Date of Injury

AUTHORITY FOR THE RELEASE OF INFORMATION

Authority for the release of information
I authorise and request Murdoch Orthopaedic Group to release to my referring medical practitioner, and/or other medical practitioners who may be involved with my medicare care, now and in the future, all such medical reports, personal information and documentation relevant to my medical care, including procedure reports, test results and hospital admissions, that may be required. I agree that I am responsible for the payment of all fees to Southern Cross Orthopaedic Group for consultation, surgery or any reports requested on my behalf for medicolegal reasons.