Patient Booking Form Page 1 of 6 14% To make a booking, a valid Doctor’s referral is required.Do you have a valid referral?*YesNoPlease send the referral via fax (03) 82560142 or email: firstname.lastname@example.org and proceed with completing this booking.Please see your Doctor to obtain a valid referral before a booking can be made. You may still proceed with this online booking; however, no appointment can be made until a referral is received.Is your condition related to a valid TAC or WorkCover claim?*YesNoPatient DetailsTitlePlease selectMr.Mrs.MissMs.Dr.Prof.Rev.Given Name*Surname*Address*Suburb*State*Please SelectAustralian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern AustraliaPostcode*Date of Birth*Day12345678910111213141516171819202122232425262728293031MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*TelephoneHomeWorkMobile*Email* Emergency InformationEmergency Contact*Telephone*Relationship*GP DetailsGP Name*Clinic Name*AddressTelephoneFax EntitlementsMedicare Number*ReferenceExpiry*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year203020292028202720262025202420232022202120202019201820172016201520142013201220112010Health Care/Pension Card NumberExpiryDay12345678910111213141516171819202122232425262728293031Month123456789101112Year203020292028202720262025202420232022202120202019201820172016201520142013201220112010Private Health InsuranceYesNoFundMembership NumberVeteran AffairsGoldWhiteNumberPlease specify conditions covered Claim DetailsPlease select*WorkCoverTACPublic LiabilityClaim Number*Insurer*Employer*Date of Injury*Day12345678910111213141516171819202122232425262728293031MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Case ManagerPhone NumberFax NumberIf you require an Interpreter, please state language spoken General Health InformationDo you take blood thinning medications? eg. Aspirin, Warfarin, Clopid, PlavixYesNoPlease indicate and specify why.Allergies?YesNoPlease list all allergiesHave you had any surgery to the relevant pain area(s)?YesNoPlease indicateHave you had any injections to the relevant pain area(s)? eg. epidurals, blocks, facet jointYesNoPlease indicateHave you ever had any Infusions of Medication? eg. Ketamine, LignocaineYesNoPlease indicateHave you ever had a trial or implant of a spinal device? eg. Pump, StimulatorYesNoPlease indicateHave you ever had rehabilitation for your pain condition?YesNoPlease indicate what type of rehabilitation and at which facilityPlease list your current Medical Practitioners/Specialists Medication ProfileList current prescribed and non-prescribed medications you are taking. (To add more, click the + button)eg: Name - Paracetamol, Dose - 1 pil, Frequency - Every 6 hoursNameDoseFrequency DisclaimerI understand the details of my medical condition(s) may be revealed for the purposes of optimising my treatment and of continuity of care. I believe the details provided to be true and correct, and hereby give permission for these to be disclosed to other medical practitioners in relation to my medical condition(s). Yes, I understand the disclaimer Do you consent to Melbourne Pain Group contacting you via SMS or Email? eg. SMS appointment reminder or emailing formsSMS*YesNoEmail*YesNoHave you sent your referral?*YesNoOur rooms will contact you to make an appointmentPlease see your Doctor to obtain a referral. You can send the referral via fax (03) 82560142 or email: email@example.com Once the referral is received, our rooms will contact you to make an appointment.