New Patient Registration

Patient Details

Title*

Full Name*

Date of Birth*

Address*

Street Address Suburb Post Code

Home Phone Number

Mobile Phone Number

Email Address*

How did you hear about Dr Sunil Reddy and Ready Orthopaedics Adelaide?

General Practitioner

Social Media/Google/Website

Past Patient Recommendation

Other

Medicare/DVA/Aged Pension Details

Medicare Number*

10 digits

Ref Number

1 digit next to cardholder's name

DVA Number (if applicable)

Gold

White

Aged Pension Details (if applicable)

Hospital Cover

Do you have Private Health Insurance?*

Yes

Hospital Cover Fund*

Member Number*

Ref Number*

(number next to your name)

Have you had cover for longer than 12 months?*

Yes

If you have not had hospital cover longer than 12 months, you are unlikely to be covered for surgery (please note “Extras Cover ONLY” does not enable patients to be covered for surgery in Private Hospital.)

General Practitioner Details

Usual GP Name

Clinic Name

Address

Fee Information

PLEASE NOTE: Referrals have expiry dates (GP Referral: 12 months / Specialists: 3 months).

It is your responsibility to ensure your referral is current at the time of your appointment, to avoid having the fee being invoiced entirely to yourself for payment. Aged concession is bulk billed however requires a valid GP referral to do so.

Initial Consult: $180 (Medicare Rebate $86.15)

Review Consult: $90 (Medicare Rebate $49.75)

Workcover Details (if applicable)

Is this a Workcover or Motor Vehicle Accident Claim?

Yes

Insurance Company*

**Although this may be a claim, the financial responsibility is to the patient, should payment be disputed or rejected by the insurer.

Claim Number*

Claim Manager Name*

Mobile Number*

Email Address*

Health Questionnaire

What is your height (cm)?*

What is your weight (kg)?*

Please list any known health conditions*

Radiology*

In order to see Dr Reddy, it is required you have had recent radiology scans. Please provide the name of where you had your last scans.

Other (Radiology)*