CG New Patient Form

First Name *

Middle Name

Surname *

Date of Birth *

Male/Female/Other

Address *

Suburb *

State *

Postcode *

Contact Number *

Number (Home/Work)

Email Address *

I am happy for letters to be sent via email? *

YesNo

Dr Graff uses software (Lyrebird) that helps create letters from the consultation. It will record the consultation, but once the letter is generated, the software will delete the recording. Your privacy and confidentiality will be maintained at all times. Please speak to Dr Graff’s secretary if you want further information.

I consent for Dr Graff to use Lyrebird dictation software during my consultations (Please see information attached): *

YesNo

Medicare Card Details

Medicare Number *

Patient Individual Reference Number (IRN) *This is the number that appears on the card next to the individual's name.

Expiry *

Private Health Insurance Details

Private Health Fund

YesNo

If yes, name of Private Health Fund

Private Health Membership Number

Type of membership (please check appropriate box)

Extras onlyHospital coverHospital cover in a waiting period

Other (please check appropriate box)

No private health coverRTWSADVAOther

Other details (if required)

General Practitioner Name

GP Practice/Suburb

Details of Physiotherapist or Podiatrist (Please complete so we can send a copy of your letter to them)

Name

Practice

Address/Suburb

Parent/Caregiver or Emergency Contact Details (please complete if Patient is under 18 years old)

Parent/Caregiver Name

Parent/Caregiver Surname

Parent/Caregiver Date of Birth

Parent/Caregiver Medicare Number

Parent/Caregiver Individual Reference Number (IRN)This is the number that appears on the card next to the individual's name.

Parent/Caregiver Medicare Expiry

Secondary Parent/Caregiver Details (if applicable)

Secondary Parent/Caregiver Name

Secondary Parent/Caregiver Surname

Relationship to patient

Secondary Parent/Caregiver Contact Number

Please tick the box below and then click 'SUBMIT' to complete this form *