New Patient Details Form


You may complete this online form prior to your appointment. It is sent via standard email security protocols. Alternatively, you may download a PDF copy. The completed form can be emailed to enquiries@shoulderspecialist.com.au or printed and brought in on the day.
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All appointments and enquiries 02 8403 8022
PHONE - Please enter at least ONE contact number
Emergency Phone - Please enter at least ONE contact number

Medicare Details

Health Insurance

Survey

Referring Doctor Details

Enter N/A if none

Physiotherapist Details

  Workers Compensation Only  

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ALL PATIENTS TO READ PLEASE


  • Settlement of your consultation account is required on the day, and payment for surgery within 14 days.
  • Any dishonoured cheques will incur administration fee of $15.
  • Any overdue consultation account and/or surgery account of 60 days will incur a $100 administration fee and over 120 days will be given to a collection agency (with your contact and account details) and will attract a 25 % service fee plus GST.
I accept responsibility for my accounts and agree to the above financial conditions.
Permission is given to release medical history to the family doctor, insurance company or solicitor.

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