Registration - Dr Ben Kenny

Name*

Prefix First Middle Last

Address*

Street Address Suburb Post code

Date of Birth*

Sex

Male
Female

Phone Home

Phone Work

Phone Mobile

Communication

We want to provide the best health care possible. Many patients find it valuable to correspond by email and SMS. These SMS and emails will contain some of your health information, however they are not a secure method of communication. If you DO NOT want to correspond via email or SMS then please tick this box.

No SMS/email

Email*

Person / Entity responsible for fees

Please choose from the below options.

Workcover / Third-Party Insurer

If insured through Workcover or a Third-Party insurance, please write down the insurer's name.

Claim number

What is the status of your claim?

Approved
Pending
Closed

Parent / Guardian full name

Parent / Guardian date of birth

Parent / Guardian Medicare No

Medicare No

Position on card

Expiry

Are you a member of a Private Health Fund?*

Yes, I am insured.
No, I am uninsured.

Private Health Fund Name

Member No

Expiry

Uninsured patient consent*

I understand that Dr Kenny works in a Private Practice setting, and that there will be fees associated with my treatment.

Yes, I understand.

Are you a DVA card holder?

Yes, I am.
No, I am not.

DVA card

Applicable if you have a Department of Veteran's Affairs card.

DVA Card Number

DVA Card Accepted Condition

Concession Card

Pension Card
Health Care Card

Card number

Referring Doctor

Practice Name

Suburb

Do you have a usual GP?

Yes, I do and this is my referring doctor.
Yes, I do and this is a different doctor.
No, I do not have a usual GP.

Usual GP name*

If different to the referring doctor

Practice Name

Suburb

No usual GP consent*

Dr Kenny routinely corresponds with your usual GP to provide continuity of care. I acknowledge, without a usual GP listed, a note will be written on file but no correspondence will be sent out.

Yes, I understand.

Occupation

Emergency contact

Relationship

Phone

Medical History

Height (cm)

Weight (kg)

Allergies/Adverse Reactions

What are your current or past health issues? Please mark and provide details.

Cardiac

Palpitations
Heart Failure
Angina
Blood Pressure
Heart Attacks
Other

Details:

Respiratory

COPD
Asthma
Sleep Aponea
Other

Details:

Gastrointestinal

Reflux
Liver Disease
Kidney Impairment

Details:

Neurological

Stroke
Pain
Other

Details:

Medications

Prescription and over the counter

Name

Dose

Frequency

Name

Dose

Frequency

Name

Dose

Frequency

Name

Dose

Frequency

Name

Dose

Frequency

Are you on any blood thinners?

eg. Warfarin, Asprin, Dabigatran, Clopidogrel.

Yes
No

Details

Have you had any problems with anaesthesia in the past?

Yes
No

Details

Personal & Health Information Consent

We respect your right to privacy and take our privacy obligations seriously. We comply with the Australian Privacy Principles, found under the Privacy Act 1988 (Cth). Our Privacy Policy can be obtained from Reception. We require your consent to collect personal information and health information about you. Please read this information carefully, and sign where indicated below. Dr. Benjamin Kenny collects information from you for the primary purpose of providing your orthopaedic services. We require you to provide us with your personal and health information including your full medical history so that we may provide our services to you. We will also use the information you provide in the following ways:

appropriately manage our practice, such as conducting audits and undertaking accreditation processes, manage billings and training staff
effectively communicate with third parties, including Medicare Australia, private health insurers, government departments and other practitioners involved in your healthcare.

I have read the information above and understand why my information is collected and how it is used. I acknowledge that I am not obliged to provide any information requested of me, but that failure to do so might compromise the quality of care provided to me. I understand that email and SMS are not a secure form of communication. I acknowledge that email and SMS will contain some of my health information and I consent corresponding via these methods.

Patient name

I have read and understand the Personal & Health Information Consent above

Yes
No

Guardian name

I have read and understand the Personal & Health Information Consent above

Yes
No

CAPTCHA

New Patient Registration and Consent Form

Medical History

What are your current or past health issues? Please mark and provide details.

Medications

Personal & Health Information Consent

Associations