New Patient Intake

Patient Registration Form

Please complete this form prior to your initial consultation with Dr. Sam Bewsher. All information provided is kept strictly confidential.

1. Personal Information

Basic contact details for patient records.

Title *

First Name *

Last Name *

Date of Birth *

Gender *

Mobile Phone *

Email Address *

Street Address *

Suburb / Postcode *

Emergency Contact / Next of Kin

Contact Name

Relationship

Contact Phone

2. Medicare & Insurance Details

Required for rebate processing and hospital bookings.

Medicare Number

Ref No. (Position on card)

Expiry Date

Private Health Fund Name

Fund Membership Number

3. Referral & Orthopaedic Condition

Details regarding your doctor's referral and affected area.

Referring Doctor / GP *

GP Clinic / Location

Affected Body Part / Joint *

Side *

Is this a WorkCover or Transport Accident (TAC) Claim?

No / Private Patient WorkCover Claim TAC Claim

Brief Summary of Symptoms / Injury

Attach Referral Letter / Scan Reports (Optional)

Accepted formats: PDF, JPG, PNG up to 10MB each.

4. Privacy & Declaration

Please review and consent to proceed with submission.

256-Bit Encrypted & Secure Storage Your personal health details are transmitted over SSL encryption and stored securely in accordance with Australian Privacy Principles (APP 3 & APP 11) and health privacy regulations.

I confirm that the information provided above is accurate to the best of my knowledge. I consent to Dr. Sam Bewsher's rooms collecting and storing my health details for medical consultation and treatment purposes in accordance with privacy regulations.