Patient Registration Form Δ NameThis field is for validation purposes and should be left unchanged.ConsentDr Sanjeev Gupta is collecting your record according to the Health Records and Information Privacy Act 2002. Please read and sign to give approval for this information to be collected and stored. Your medical information will be used exclusively for providing health care in the following way:To gain a history, diagnose disease and provide treatment where necessaryAdministrative purposes in running this Practice, which may also include confirmation of your appointmentWriting reports to your Doctor and other Doctors involved in the provision of healthcare, and the storing of reports provided to this Practice by other Medical SpecialistsBilling and collection purposes, including but not limited to compliance with Private Health Fund, Medicare and Health Insurance Commission requirementsYou may gain access to your health information by writing to us If you do not consent to providing us with your health information we may be unable to provide you with health services.I consent to the handling of my information by this practice as outlined above: Yes NoPersonal DetailsGenderPlease selectMaleFemaleNon-binaryAgenderMy gender is not listedPrefer not to answerTitlePlease selectMrMrsMstMsDrProfOtherSurname*Given Name(s)*Phone number*Alternative phone number (if applicable)*Date of Birth* DD slash MM slash YYYY Email* Next of Kin / Emergency NameNext of Kin / Emergency ContactRelationshipOccupationMedicare and Health FundMedicare Number*Month*Please selectJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear*Ref*Health InsurancePlease selectPrivatePublicDVAWorkcoverThird-partyOverseasOtherHealth Fund DetailsPlease selectBUPAHCFTeachers HealthNIBMedibank PrivateOtherMembership NumberReferenceMedical QuestionnaireCondition for review Hip Knee Trauma OtherSide Left Right BothIs this related to an injury? Yes NoInjury detailsHave you had Xrays / CT scan / ultrasound / MRI scans? Yes NoUpload Scan files Drop files here or Select filesMax. file size: 3 MB, Max. files: 5.Previous Orthopaedic Surgery Yes NoPrevious Orthopaedic Surgery DetailsCurrent treatment for your conditionPain tabletsPlease provide detailsAnti-inflammatoriesPlease provide detailsOther allied healthPlease provide detailsPhysiotherapyPlease provide detailsCurrent medical issuesSmoking Yes NoHeart condition Yes NoAlcohol Yes NoLung condition Yes NoKidney or urinary condition Yes NoNeurological condition Yes NoSkin condition Yes NoDiabetes Yes NoHistory of blood clots Yes NoOther blood disorders Yes NoPrevious cancer Yes NoViral condition / hepatitis /HIV Yes NoIf you have answered “yes” to any of the above questions, please provide details of the condition and the names of the Specialists you see:*CAPTCHA Δ PhoneThis field is for validation purposes and should be left unchanged.ConsentDr Sanjeev Gupta is collecting your record according to the Health Records and Information Privacy Act 2002. Please read and sign to give approval for this information to be collected and stored. Your medical information will be used exclusively for providing health care in the following way:To gain a history, diagnose disease and provide treatment where necessaryAdministrative purposes in running this Practice, which may also include confirmation of your appointmentWriting reports to your Doctor and other Doctors involved in the provision of healthcare, and the storing of reports provided to this Practice by other Medical SpecialistsBilling and collection purposes, including but not limited to compliance with Private Health Fund, Medicare and Health Insurance Commission requirementsYou may gain access to your health information by writing to us If you do not consent to providing us with your health information we may be unable to provide you with health services.I consent to the handling of my information by this practice as outlined above: Yes NoPersonal DetailsGenderPlease selectMaleFemaleNon-binaryAgenderMy gender is not listedPrefer not to answerTitlePlease selectMrMrsMstMsDrProfOtherSurname*Given Name(s)*Phone number*Alternative phone number (if applicable)*Date of Birth* DD slash MM slash YYYY Email* Next of Kin / Emergency NameNext of Kin / Emergency ContactRelationshipOccupationMedicare and Health FundMedicare Number*Month*Please selectJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear*Ref*Health InsurancePlease selectPrivatePublicDVAWorkcoverThird-partyOverseasOtherHealth Fund DetailsPlease selectBUPAHCFTeachers HealthNIBMedibank PrivateOtherMembership NumberReferenceMedical QuestionnaireCondition for review Hip Knee Trauma OtherSide Left Right BothIs this related to an injury? Yes NoInjury detailsHave you had Xrays / CT scan / ultrasound / MRI scans? Yes NoUpload Scan files Drop files here or Select filesMax. file size: 3 MB, Max. files: 5.Previous Orthopaedic Surgery Yes NoPrevious Orthopaedic Surgery DetailsCurrent treatment for your conditionPain tabletsPlease provide detailsAnti-inflammatoriesPlease provide detailsOther allied healthPlease provide detailsPhysiotherapyPlease provide detailsCurrent medical issuesSmoking Yes NoHeart condition Yes NoAlcohol Yes NoLung condition Yes NoKidney or urinary condition Yes NoNeurological condition Yes NoSkin condition Yes NoDiabetes Yes NoHistory of blood clots Yes NoOther blood disorders Yes NoPrevious cancer Yes NoViral condition / hepatitis /HIV Yes NoIf you have answered “yes” to any of the above questions, please provide details of the condition and the names of the Specialists you see:*CAPTCHA
