New Patients Form Section 1: Personal Details MrMrsMsMissMasterDr First Name Surname Name Address Suburb Postcode Phone Email Date of Birth Parents Full Name (if under 18) Do you have health insurance extras? YesNo If yes, which fund? Do you have a Centrelink Pension or Health Care Card? YesNo CRN Number Expiry Date Current GP / Clinic Name Did they refer you? YesNo How did you hear about us? Friend / FamilyWebsiteInternet (eg Google)Other Next of Kin First Name Surname Name Mobile Number Home Number Work Number Relationship to you Is your visit covered by any of the following? Department of Veterans Affairs: YesNo If Yes, is your card Gold or White GoldWhite If White, list condition Travel Accident Commission (TAC) Yes (Please complete Section 2)No Workcover Authority Yes (Please complete Section 3)No Section 2: Travel Accident Commission (TAC) Date of Accident Claim Number Case Manager Name Contact Number Section 3: WorkCover Authority / WorkSafe Victoria Date of injury Claim Number Employer / Business Name Address Suburb Postcode Contact Name Contact Number Email Name of Insurer (if known) Case Manager Name (if known) Contact No. / Email I acknowledge that it is my individual responsibility to pay for appointment fees on the day of appointment, or for any outstanding balances for services previously provided. This will also apply for Medicare and insurance purposes (eg WorkCover, TAC, etc) should my claim be unsuccessful.