New Patient Form Name(Required) Date of Birth Day Month Year Best contact number(Required) Email(Required) Address Street Address Address Line 2 City State / Province / Region Postcode Name of Referring GP Name of Referring Practice Attach GP Letter of Referral Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 20 MB. Medicare Number Including ref no.Medicare Expiry Date mm/yyyyPrivate health fund Private health fund number Including ref no.Which knee? Left Right Both Recent injury or longstanding? Recent Longstanding Any previous knee surgery? Yes No Have you had x-rays? Yes No Where and when did you have the x-rays done?Have you had an MRI? Yes No Where and when did you have the MRI done?Your height in cms Your weight in kgs Do you have diabetes? Yes No Do you have sleep apnoea? Yes No Do you smoke? Yes No Do you have cardiac issues? Yes No Are you covered for joint replacement? Yes No Should you have an idea already that you may need a knee replacement, please check with your health fund that you are specifically covered for this. Joint replacement was removed from some private health insurance policies and this comes as a surprise to patients who then have to wait one year.CAPTCHA
