New Patient Form

Personal Information

Title

First Name *

Surname *

Date of Birth *

Email Address *

Home Phone

Mobile Phone

Street Address *

City *

State *

Postcode *

Country

Occupation

Work Phone

Next of Kin

Next of Kin Phone Number

Medical Information

Medicare Number *

Medicare Reference Number *

Medicare Card Expiry Date

Referring Doctor

Your Usual GP

Insurance Details

Not all of the below sections will be applicable to your situation. Please fill in all relevant information

Insurance Status

If other, please explain

Date of the injury

Insurer

Employer

Employer Phone Number

Employer's Street Address

City

State

Postcode

Country

Workcover or MVA Claim Number

Claim Manager

Claim Manager's Phone Number

Claim Manager's Email Address

Private Insurance Insurer

Private Insurance Membership Number

Have you had private insurance for more than 12 months?

Aged Pension Expiry Date

DVA Gold Card Number

DVA White Card Number

Privacy and Telehealth Consents

Privacy Statement

In consenting to consultation and mutually agreed treatment, I understand that:
- A written record of history and examination relative to my condition will be recorded in the casenotes/computer records of Dr. Nimon.
- It may be necessary to share information with other Health Providers, eg (General Practitioner, Orthopaedic Colleague, Pathology, Radiology, Physio, Podiatry Services), for further investigation and treatment of my condition.
- There may be a legal request/s that cannot be refused, outside of my personal privacy rights.
- I consent to requested reports being sent to Workcover or insurer (if applicable).
- I undertake to notify Dr. Nimon of any specific information I do not wish forwarded to the above alternative Health Providers.
- I give consent for material (photos or x-rays) to be used for teaching/research or website purposes.
- I accept responsibility for the full financial settlement of my account to be paid on the day of consultation, unless I am covered by Workcover with an accepted claim (unless I am unable to provide accepted Workcover claim details or if the indicated claim has been suspended or closed). I accept that default can result in my personal details being forwarded to a Debt Collection Agency, for pursuit of outstanding amounts, which will incur further fees to be paid by myself.
A copy of Dr. Nimon's Privacy Policy for protection of patient confidentiality is available for perusal, on request, from the Practice Manager/ Privacy Officer. Please direct any enquiries to the Practice Manager/ Privacy Officer

I agree to the Privacy Statement *

I agree to the Privacy Statement

Telehealth Consent

I give my authorisation for Dr Nimon to provide me with Telehealth Consultations which will then be billed through Medicare.

Do you agree to Telehealth Consultations?

I agree to TelehealthI do not agree to Telehealth

47 Broadway

Glenelg South SA 5045

New Patient Form