Patient Registration Form

General Information

First Name *

Last Name *

Title

Pronouns

Date of birth *

Email Address *

Home phone

Mobile phone *

Residential Address *

Traditional Place Name

Country

Town/City *

State

Postcode

Do you have a different postal address?

Postal Address

Are you of Aboriginal or Torres Strait Islander origin?

Medical Identification

Gender *

Medicare *

Ref No *

Exp Mth *

Exp Year *

Do you have a DVA Card?

DVA Type

DVA Card Number

DVA Expiry Date

Do you have a Pensioner Concession Card or Health Care Card?

Pensioner Concession or Health Care Card Number

Pensioner Concession or Health Care Card Start Date

Pensioner Concession or Health Care Card Expiry Date

Regular GP

Regular GP Practice

Do you have a Private Health Fund?

Private Health Fund

Member Number

Card Ref No

Emergency Contact Information

Emergency contact *

Phone *

Relationship to you *

Are you attending South Coast Sports Medicine to see a Physiotherapist or Exercise Physiologist? *

YesNo

Are you attending South Coast Sports Medicine in relation to a compensation claim or work injury? *

Are you attending South Coast Sports Medicine for a Medicinal Cannabis appointment? *

Third Party Funding

Do you have NDIS funding? *

NDIS ID

Plan start date

Plan End Date

Do you have a support co-ordinator? If so, please provide name, contact number and email address

Do you have a plan manager? If so, please provide details including name, contact number and email

Occupation

Case Management

Insurer

Claim ID

Case Contact Name

Employer

Contact Name

Contact Number

Notice regarding payment

I understand that if I don't provide a valid Claim ID that I am liable for payment which I can then have reimbursed by the insurer. *

Örebro Musculoskeletal Screening Questionnaire

These questions and statements apply if you have aches or pains, for example back, shoulder or neck pain. Please read and answer each question. Each question needs a response.

Not At All

Extremely

Not At All

Extremely

Never

All the time

Örebro Musculoskeletal Screening Questionnaire continued...2

We also need a bit more information on your thoughts and feelings. Each question needs a response.

Not At All

Extremely

Not At All

Extremely

No risk

Very large risk

Not At All

Extremely

Örebro Musculoskeletal Screening Questionnaire continued...3

How true are the next two statements for you? Each question needs a response.

Not At All

Extremely

Not At All

Extremely

Help us to better understand your current physical abilities. Each question needs a response.

Not At All

Completely normal

Not At All

Completely normal

Orebro-12 Score is

Medicinal Cannabis Questionnaire

What are your presenting conditions and or symptoms *

Are you currently taking any medication? *

YesNo

Do you suffer or have you suffered from any of the following? *

Mental IllnessHistory of Dependency (Medication, drugs, alcohol, nicotine)History of sensitivity or allergy to cannabis or other medicationEpilepsyNone of the above

Do you have any medication allergies? *

YesNo

How many hours a night do you sleep? *

Do you exercise? Please list if you do, how many times a week & type *

YesNo

Exercise Details

Do you meditate? *

YesNo

Are you at risk of falls? *

YesNoNot sure

Are you required to drive? *

YesNo Sometimes

Do you look after small children? *

YesNo Sometimes

What is the primary diagnosis or medical condition you are looking to treat with medicinal cannabis? *

If other please list

Are you or have you used recreational cannabis? If yes, what and how much, since when or how often? *

Are you currently taking medicinal cannabis? Is yes please provide details below including what, how much, since when and prescribed by whom? *

What other treatments have you trialed for this condition? *

Medicinal Cannabis Patient Declaration

I understand that the long term side effects of medicinal cannabis are unknown. *

YesNo

I understand that medicinal cannabis is not registered in Australia by the Therapeutic Goods Administration of the Australia Department of Health and Aging. Therefore, arrangements to access/import these medicines need to be made through a Special Access Scheme of Authorised Prescriber Scheme. *

YesNo

I understand that the Australian governments Therapeutic Goods Administration (TGA) does not guarantee quality, safety and efficacy of medicinal cannabis. *

YesNo

I understand that the prescribing doctors may report my treatment outcomes to the state government *

YesNo

I understand that the cost of medicinal cannabis is solely my responsibility. *

YesNo

I understand that it is an offence to drive in Australia with any level of tetrahydrocannabinol (THC) in my blood or saliva and if I drive, I am breaking the law. A legally issued prescription is not protecting against these laws. *

YesNo

I understand the risks and complications associated with medicinal cannabis treatment and I agree to follow my doctor's recommendations with regards to dosing and report any adverse effects or medicinal cannabis, including changes in the levels of sedation, lethargy, fatigue, dry mouth, nausea, vomiting, diarrhea, drowsiness, dizziness, disorientation, agitation, balance problems, changes in memory, paranoid delusions or hallucinations. *

YesNo

I understand that there is a possibility of unknown risks and late side effects *

YesNo

I understand that medicinal cannabis might interact with my other medications and doses may need to be adjusted accordingly. *

YesNo

I agree to keeping a log of my doses and changes in symptoms due to medicinal cannabis *

YesNo

I agree to regular follow up consultations in the surgery or over the phone as indicated by my doctor. *

YesNo

I agree that I will not use any other forms of cannabis other than what is prescribed by my doctor, this includes any elicit forms of cannabis (marijuana) *

YesNo

I agree to notifying my prescribing doctor of any changes in my other medications *

YesNo

I agree to share my clinical outcomes for research purposes *

YesNo

Medical Profile

Is there anything else important that we need to know about you and your health care? Ie Allergies

Pre-Exercise Alert

Patient Consent & Indemnity

Please read this form carefully before signing

Collection and Use of Information
Our practice collects your personal and health information to provide safe, effective, and high-quality healthcare, including assessment, diagnosis, treatment, rehabilitation, and exercise programs.

This information may include consultation notes, medical history, medications, allergies, test results, referrals, specialist correspondence, billing and administrative records, and information collected through clinical tools (including AI-assisted documentation).

Your information may be used for:

Managing your care and practice administration
Billing and Medicare compliance
Sending appointment reminders and follow-ups
Communicating with other healthcare providers involved in your care
Meeting legal and regulatory obligations
Internal use within the practice if you are treated by multiple clinicians
De-identified research and quality improvement

We respect your privacy and handle your information in accordance with the Privacy Act 1988 and Australian Privacy Principles. Our full privacy policy is available on request.

Consent and Privacy
By signing this form, you:

Consent to the collection, use, and disclosure of your information as outlined above
Consent to being contacted via SMS, phone, or email where relevant
Understand that only necessary information will be shared
Acknowledge that you may withdraw or modify your consent at any time in writing
Agree to keep your personal details up to date

Acknowledgement of Risk & Indemnity
I understand that participation in treatment, exercise, or rehabilitation programs involves physical activity and carries inherent risks, including possible injury. I confirm that I have disclosed all relevant medical or health conditions that may affect my ability to participate safely. I accept responsibility for my personal belongings and equipment.

In the event of injury, accident, or illness, I consent to receive medical treatment deemed necessary by the treating practitioner.

To the extent permitted by law, I understand that the practice, its staff, and owners are not liable for any injury, loss, or damage arising from my participation, except where caused by negligence.

Payment & Cancellation Policy
I consent to a cancellation fee of $30 if I cancel my appointment with less than 24 hours notice or fail to attend for any reason. I understand this fee is not eligible for Medicare nor DVA rebates and will not be covered by insurance for workers compensation claims.

I understand that South Coast Sports Medicine is a private practice and payment is required on the day. EFTPOS and Tyro facilities are available.

I have read and understood this form and agree to the terms outlined above. *

Signature

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