Patient’s Form

Patient Details

Next of kin/contact person in an emergency

Medicare Details Not Applicable

Private Health Insurance Not Applicable

Veteran Affairs Card No

General Practitioner (please list your usual G.P. or the doctor you would attend if medically required)

Other health care providers (e.g. rheumatologist, endocrinologist, physiotherapist, chiropractor, osteopath)

Past Medical HistoryI have no medical conditions

( Please select any of the medical conditions below that apply to you. For each medical condition please enter the medication dose and frequency you take for it)

  We respect your privacy. All information collected is stored securely and accessed only by our staff. In order to provide the highest standard of podiatric care, there are times when we may communicate with other healthcare providers.

  I have read the privacy information and consent to collection and dissemination of information as described. I understand provision of my medical history is necessary to provide me with effective, safe and efficient podiatric management. I have answered all questions to the best of my knowledge. I agree to notify the podiatrist and/or the podiatric surgeon of any change in my health.

  Dr Robert Hermann is a podiatric surgeon and not a medical practitioner – therefore his fees are NOT COVERED BY MEDICARE. I confirm that I am aware of these facts.