Patient Intake Form (Child)

Please fill out all required fields below and submit your form prior to your child’s appointment. Private Hospital Health Insurance Cover is required to see A/Prof Donnan (not required for TAC or hip dysplasia babies). When selecting dates greater than one year prior, click the year field and manually type in the relevant year to quickly access the date.

Patient's or Child's First Name

Patient's or Child's Surname

Date of Birth

Sex

Home Address

State

Postcode

Home Phone

Contact Email Address

Presenting Problem

Referring Doctor

Address of Referring Doctor

Phone Number

Family Doctor

Address of Family Doctor

Phone Number

Patient's Medicare Number

Medicare Reference

First Parent/Guardian's Full Name

First Parent/Guardian's Contact No.

First Parent/Guardian's Medicare Number

Parent/Guardian's Medicare Reference

First Parent/Guardian's DOB

Second Parent/Guardian's Full Name

Second Parent/Guardian's Contact No.

Health Insurance Fund

Membership Number

Person responsible for account (if different from patient)

TAC Claim Number (if applicable)

Medical History

Past Medical History Including Surgical Procedures

Specialist/Doctor

Medical History

Past Medical History Including Surgical Procedures

Specialist/Doctor

Medical History

Past Medical History Including Surgical Procedures

Specialist/Doctor

Allergies & Reactions

Current Medications

Upload your patient referral (if available)

Up to three files allowed. Hold down SHIFT to multiple select.

Fees & Acceptance Of Terms

The full fee is payable on the day of consultation by cash, cheque, credit card or EFTPOS. Cards accepted are VISA, MasterCard or Amex. We do not accept Diners.

In the event where your overdue account is referred to a collection agency and/or law form, you will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand costs.

Initial Consultation = $260.00 • Medicare Rebate applies
Review Consultation = $160.00 • Medicare Rebate applies

I acknowledge that the full fee is payable on the day of consultation.

I have read and accept the terms and conditions of the Practice Privacy Policy.

I consent to receiving correspondence via secure password protected email.