Dr Mike Smith New Patient Form Title* Mr Mrs Ms Miss Master Dr First Name* Last Name* Preferred Name Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Occupation Contact DetailsHome Phone NumberWork Phone NumberMobile Phone NumberEmail Address Street Address Suburb State / Province / Region ZIP / Postal Code Next of KinFull Name PhoneRelationshipSELECT AN OPTIONParentSonDaughterSpousePartnerSiblingRelativeFriendOtherReferring DoctorName of Referring Doctor* Referring Doctor's Clinic* Is this your usual GP* Yes No Usual General Practitioner Usual General Practitioner's Clinic Podiatrist Name and Clinic Physiotherapist Name and Clinic Healthcare DetailsMedicare Number* Medicare Reference*Reference number is the number next to your name on the card. Expiry Month*SELECT MONTH010203040506070809101112Expiry Year*SELECT YEAR20242025202620272028202920302031Private Health DetailsFund NameSELECT FUNDACA Health Benefits FundAHM Health InsuranceAustralian Unity health LimitedBUPA AustraliaCBHS Health FundCDH Benefits FundCUA Health LimitedDefence Health LimitedDoctors Health FundGMF HealthGMHBA LimitedGrand United Corporate healthHBF HealthHCFHealth Care Insurance LimitedHealth Insurance Fund of AusytaliaHealth partnersLatrobe HealthMedibank PrivateMildura Health FundNavy HealthNIB Health FundPeoplecare Health FundPolice HealthQueensland Country Health FundRailway & Transport Health FundReserver Bank health SocietySt. Lukes HealthTeachers Health FundTransport HealthTUHWestfund limitedFund Number Select if applicable Workcover 3rd Party Claim number Insurer Employer Claim Manager's Email Date of Injury DD dash MM dash YYYY Do you have a concession card Yes No Type of Concession Card Aged Pension Disability Healthcare Card DVA Card Aged Pension Card Number Expiry MonthSELECT MONTH010203040506070809101112Expiry YearSELECT YEAR20172018201920202021202220232024202520262027Disability Card Number Expiry MonthSELECT MONTH010203040506070809101112Expiry YearSELECT YEAR20172018201920202021202220232024202520262027Healthcare Card Number Expiry MonthSELECT MONTH010203040506070809101112Expiry YearSELECT YEAR20172018201920202021202220232024202520262027DVA Card TypeGOLDWHITEORANGEDVA Number Medical QuestionnaireHow did you hear about usGP ReferredFriend or FamilySocial MediaMessenger / PaperSearch EngineOtherOther Please complete how you heard about usThe consultation fees charged by Dr Smith are based on the AMA Schedule of Fees, and are as follows: Initial Consult: $195 (Aged Pension $165). Review of Consult: $120 (Aged Pension $95). ACCOUNTS ARE PAYABLE IN FULL ON THE DAY OF CONSULTATION It is a term of the provision of these services that the patient shall be liable for all debt collection fees and charges, including but not limited to agent fees, solicitor costs and disbursements in the event that the collection is required. Please note that Medicare does not completely cover the cost of your consultation. Workcover and Third Party claims are managed separately. Other fees may be incurred for fractures and their management, casts, boots, injections, splints etc and for completion of medical forms for insurance, income protection and other such forms. I understand that payment of the account is my full responsibility. I consent to the release and communication of information from and to any other medical provider, for the purpose of my ongoing clinical management and for ongoing clinical research, audit and education (letters, Images, and Video). Clinical images may be used in a de-identified manner for marketing or education purposes. Dr. Smith is a design Surgeon for some of the equipment utilised in Keyhole Bunion Surgery within Australia, and receives financial compensation for this.I agree with the above Yes No Signature