Focus Shoulder Specialists

Patient Information Sheet

Title

Name*

First Last

Date of Birth*

Occupation*

Address

Postcode

Phone

Mobile*

Email*

Emergency Contact

Relationship

Mobile

Medicare No.

Expiry Month

Expiry Year

Your reference number on card

Private health insurance:

Yes

No

Fund Name

Member No

HCC/Pension No

Expires

Type

Gold

White

DVA No

Referring doctor

Phone

Is this a GP or a Specialist?

GP

Specialist

If this is not your regular General Practitioner, please give detail

Phone

Address

Postcode

Physiotherapist

Phone

Address

Email

How did you hear about us?

How did your injury occur?

Worker's Compensation / 3rd Party Details

Date of Injury

Claim Number

Employer/Company Name

Contact Name

First Last

Phone

Employer/Company Address

Postcode

Insurance Company

Insurer Address

Contact/Case manager details

First Last

Phone

Email

The above details are true to the best of my knowledge and permission is hereby given to release medical details to my local doctor, solicitor or insurance company.

Signed

Date

Print Name

Consent to collect patient information

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so we may properly assess, diagnose, treat and be proactive in your health care needs.
We will use the information you provide in the following ways:

Administrative purposes for operating our medical practice.
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
X-rays, imaging and photographs may be shared with our online community for educational purposes. We take great care to protect patient privacy and will not disclose any identifying information. If you are a patient and do not wish for your medical information to be used in this way, please inform us immediately so that we can respect your wishes. Our primary goal is to provide education and training for healthcare professionals, and we thank you for your understanding.

Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you. If you would like to see the detailed consent, please advise one of the administrative staff.

Medicare partially covers the cost of your consultation. The full consultation fee is payable in on the day the consultation. The Medicare rebate can then be claimed back.

Phone/Telehealth Consultation agreement – due to COVID-19 restrictions Dr Dan may call you instead of a face to face consult. These appointments will be bulk billed direct to Medicare.

New Consultations $280

New Consultations (Fracture) $310

Second Opinion consultations $360

Follow-up appointments $95

Note: The 2 week and 6 week appointments post-surgery are included in the surgical fee. Appointments after 6 weeks are considered Follow-up appointments.

Signed*

Date*

Patient Name (Please print):*

Phone

This field is for validation purposes and should be left unchanged.

All new patients are required to complete the following form.

Patient Information Sheet

Worker's Compensation / 3rd Party Details

Medical Allergy and Surgical History

Medical History

Arthritis

Liver Disease

Thyroid conditions

Cardiac Problems

Lung Conditions

Cancer?

Shoulder Symptoms

Do you, or have you had any shoulder:

To treat your symptoms have you had any:

The American Shoulder & Elbow Society Rating Scale

Consent to collect patient information

Address

Address

Address