Patient Registration

Your Name*
Prefix First Name Surname
Phone*
Email*
Address*
Street Address Address Line 2 City State Postcode
Date of Birth*

Day
Month
Year
Age*
Country Of Birth*

Health Information Privacy Policy
Medical records containing personal information will be maintained throughout your treatment. These records will contain information including, but not exclusive to, your name, address, date of birth, Medicare number and your referring doctor’s details. During the period of assessment and ongoing management, information of relevance is recorded in clinical notes. These records are stored securely and may be kept for up to seven years following your last consultation. If necessary, for the continuity of your medical care, this information may be shared with other health practitioners involved in your treatment. In certain circumstances there may be a legal obligation to disclose clinical information.
I acknowledge that:*
- Details about my health will be recorded by All Pain Care in a confidential file. This file may be in a scanned or paper-based or digital format.
- my consent will apply to this and subsequent consultations, until withdrawn by me in writing.
I consent to allowing All Pain Care to:*
- take a medical history and to collect personal information about me in order to attend to my health needs and for associated administrative purposes;
  pass on/discuss relevant medical information about me to my referring doctor and any health care provider to whom I am referred by my consulting doctor;
  pass on/discuss relevant medical information about me to insurance or legal representatives (for example insurer, employer, solicitor) in the case of Third Party or Workers’ Compensation matters.
  include information about my treatment on my printed receipt to enable me to claim my medical rebate entitlement; request relevant medical information regarding my medical history from other doctors or health care professionals involved in my care; recall me for follow up of medical problems as deemed necessary;
  disclose relevant de-identified medical information for research and quality assurance activities to improve individual and community health care and practice management;
  Refer for and provide physiotherapy treatment, including documentation and storage of clinical information and discussion of clinical information with other medical and health care providers and legal/compensation/insurance representatives.
  I understand that I am not obliged to provide any information requested of me. I also understand that failure to provide this medical practice with all the information it needs may restrict the practice’s ability to provide the quality of health care and treatment that I want;
  Note: If you are a guardian this policy is to be read as from the perspective of the patient for whom you are a guardian.
I have filled out this form to the best of my ability and by pressing submit understand this to be by way of electronic signature.
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Dr David Manohar

For Patients

Patient Registration Form

Step 1 of 7 – Patient Details

Insurance & Medicare Details

Referral Details

Your GP

Tell us about your pain

How did you get hurt?

Regarding Work

Medication and Other Information

Health Information Privacy Policy

I have filled out this form to the best of my ability and by pressing submit understand this to be by way of electronic signature.

About Dr David Manohar

Dr David Manohar is a dual-Fellowed specialist, holding specialist accreditation in both pain medicine and rehabilitation medicine.

About Us

Consulting Locations

Phone

02 9521 2928

Email

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