New Patient Registration Form

Which surgeon have you been referred to see?

Dr Ben Green

Dr Beth Campbell

Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

If we are unable to contact you, would you like us to leave a message?

Yes

No

Are you a DVA card holder?

Yes

No

DVA card type

Gold

White

Do you have private health insurance?

Yes

No

Do you have private insurance for hospital cover?

Yes

No

Next of Kin

First Name

Last Name

Next of kin phone number

(###)

###

####

Do you have a current referral?

You cannot be seen without a referral. GP referrals must be written within 12 months. Specialist referrals must be written within 3 months.

Yes

No; I will be bringing this with me

Referring doctor

First Name

Last Name

Referring doctor phone number

(###)

###

####

GP contact details

(if different from referring doctor)

First Name

Last Name

GP phone number

(###)

###

####

Smoking status

Are you a current or ex smoker of cigarettes?

No

Yes, current smoker

Ex-smoker, quit more than 3 months ago

Ex-smoker, quite less than 3 months ago

Are you a diabetic?

No

Yes, insulin

Yes, not taking insulin

Are you on blood thinning medication

e.g. warfarin, plavix, aspirin, clopidogrel, xeralto

No

Yes

Clinical Photography *

Photos are an important aspect of providing clinical care. Clinical photos are often used in theatre and after to proved the best care possible. Do you agree to clinical photos being taken to aid clinical care, record keeping and medicare requirements? Dr Green and Dr Campbell may need to share photos with other health professionals involved directly with your care (you will be informed of this if required). Photos are not published on any external service without prior written consent and will not be shared with any other 3rd party without your prior written consent. Fore more information please refer to our Privacy Policy.

Yes

No

Fees *

Consultation fees do apply and need to be finalised at the time of your appointment. Fees for radiology and pathology are not under the control of BBSC. These are payable to radiology and pathology companies as per their policies. If you have questions about additional fees, please discuss with your doctor when request forms for these services are provide. Surgical fees will be provided to you as part of informed financial consent prior to your surgery. Our fees policy will be explained prior to your surgery which may require non-refundable deposits, full payment prior or delayed payment of rebates if billed through Medicare or your health fund.

I agree to fees associated with my initial consultation and acknowledge radiology and pathology fees are separate to BBSC.

I do not agree to fees and would like to discuss with the BBSC team.

Patient Privacy *

Our staff will not disclose this information to any third party. Your information is stored on a secure password protected information system. Onward referral to another specialist will require duplication of this form, your record and test results. If results are not received by the practice, our staff may call the organisation that performed the tests to receive a copy by mail, fax or electronic methods. Your records and information may be kept by your doctor at another location. Your information may be used for billing purposes including bad debt management. If you do not give permission for the above please let our reception team know. Access to your medical records may be allowed in accordance with the appropriate section of the National Privacy Act 1988. Do you acknowledge you have read the above information and the information you provided is accurate? By submitting this form you you agree to email notification of our staff and proved your consent to the above information.

Yes

No

Use of AI in our practice *

We use the program Lyrebird to help us delivery your care. This is a transcription service which helps write your consult notes and letters. Please refer to our Privacy Policy to the right of screen for more information. Are you happy for your doctor to utilise Lyrebird during your consultation?

Yes

No