Paediatric plastic or hand surgery registration

Step 1 of 5

Patient information

Patient Name

Title Given name(s) Preferred name Surname

Date of Birth

Home phone

Mobile phone

Medicare number

Enter Medicare number (no spaces needed)

Medicare reference number

Please enter a number from 1 to 9.

Month

Medicare expiry month

Year

Medicare expiry year

Dominant hand

Do you need an interpreter?

yes

What language interpreter do you require?

With adequate notice, we can organise a TIS Online video interpreter for eligible appointments. If you access an Auslan interpreter through NDIS funding, please continue to arrange this as you normally would.

Address

Street Address

Address Line 2 (optional)

Suburb

State

Postcode

Next of Kin

Next of Kin relationship

Next of Kin contact phone number

Parent information

Parent 1

Prefix First Last

Parent 1 mobile phone

Parent 1 email

Parent 2

Prefix First Last

Parent 2 mobile phone

Parent 2 email

If your child is under 12 years of age

When a child is under 12, we require the parent or guardian’s Medicare details in order to submit the claim to Medicare on your behalf and process your rebate. We therefore request the following details for the relevant parent or guardian: – Medicare number (including the reference number – usually the first number next to the name on the card) – Full name – Date of birth – Medicare card expiry date

Date of Birth

Medicare number

Enter Medicare number (no spaces needed)

Medicare reference number

Please enter a number from 1 to 9.

Month

Medicare expiry month

Year

Medicare expiry year

Fracture information

What date did the fracture occur?

How did the fracture occur?

Has your fracture been immobilised (splint, cast, buddy strap)?

yes

Where were the x-rays of your child's fracture performed?

If the x-ray report is not contained within your child’s referral, please advise where your x-rays were performed. We need to obtain access to the images before your child’s consultation can proceed.

Help us obtain all your relevant test results before your consultation

Has your child had any recent tests for the hand/wrist?

yes, radiology tests

yes, nerve conduction studies

Radiology tests include x-ray, ultrasound, CT and MRI.

Nerve conduction studies provider/ location

Please advise where the nerve conduction studies were performed, or which doctor’s office may hold a copy of the test results

Radiology provider/ location

If your child has had relevant imaging performed at more than one provider/clinic/hospital please list them all

Please upload any relevant test results/reports that you have

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 2 GB.

If not already provided within your referral, please upload any supporting information that may assist Dr Tomlinson in the analysis of your condition, such as radiology reports (x-ray, ultrasound, CT, MRI) and nerve conduction studies. If there is a visible abnormality, please upload photographs of the relevant body part.