Title *

First Name *

Last Name *

Preferred Name

Date of Birth *

Occupation

Contact Details

Home Phone Number

Work Phone Number

Mobile Phone Number

Email

Address

Address Line 1

Address Line 2

City

State / Territory

Postal

Next of Kin

Name

First

Last

Phone

Relationship

Referring Doctor

Weight Name above

Name of Referring Doctor *

Referring Doctor's Clinic *

Is this your usual GP *

Yes
No

Podiatrist Name and Clinic

Physiotherapist Name and Clinic

Healthcare Details

Medicare Number *

Expiry Month

Expiry Year

Private Health Details

Fund Name

Fund Number

Select if applicable

Workcover
3rd Party

Do you have a concession card

Yes
No

Medical Questionnaire

How did you hear about us

Do you have any of the following medical conditions *

Height (cm) *

Weight (kg) *

The consultation fees charged by Dr Smith are based on the AMA Schedule of Fees, and are as follows: Initial Consult: $210 (Aged Pension $170). Review of Consult: $125 (Aged Pension $100).

ACCOUNTS ARE PAYABLE IN FULL ON THE DAY OF CONSULTATION

It is a term of the provision of these services that the patient shall be liable for all debt collection fees and charges, including but not limited to agent fees, solicitor costs and disbursements in the event that the collection is required.

Please note that Medicare does not completely cover the cost of your consultation.

Workcover and Third Party claims are managed separately. Other fees may be incurred for fractures and their management, casts, boots, injections, splints etc and for completion of medical forms for insurance, income protection and other such forms.

I understand that payment of the account is my full responsibility. I consent to the release and communication of information from and to any other medical provider, for the purpose of my ongoing clinical management and for ongoing clinical research, audit and education (letters, Images, and Video). Clinical images may be used in a de-identified manner for marketing or education purposes. Dr. Smith is an Industry design Surgeon for some of the equipment utilised in Keyhole Bunion Surgery within Australia, and receives financial compensation for this. Dr. Smith is a founding surgeon involved in Eastwood Private Hospital. He has a financial interest in the facility and services available within the Hospital. This will not impact clinical decision making and recommendations for his patients.

We collect your personal and health information to provide you with orthopaedic care, to communicate with your referrer and other treating practitioners, for billing (including Medicare, health funds and, where applicable, your compensation insurer), and to run our practice. We use secure digital systems, including AI tools that assist with clinical notes and administrative tasks — always reviewed by Dr Smith — and some of our service providers store data overseas, including in the United States. Our full Privacy Policy, including how to access or correct your information and how to make a complaint, is available at www.drmikesmith.com.au

I agree with the above *

Yes
No

Dr Mike Smith New Patient Form