Specialist Plus
About
Our Doctors
Practice Locations
Services
Providers
Medical Director
Occupational Physician
Pain Medicine Physician
Consultant Psychiatrist
General Physician
General Surgeons
Obstetrics and Gynaecology
Dentist
Consultant Radiologist
Occupational Medical Registrars
Medical Practitioner
Forms
Consent Form
Pain Form
Contact Form
GP Education
Join Us
Contact
Call Us
Consent Form
Fill out your details below. Submitting will generate a filled PDF for download.
First Name
Surname
Middle Name
Preferred Name
Date of Birth
Phone (Home)
Phone (Mobile)
Email
Home Address
Street
Suburb/City
State
Postcode
Next of Kin
Full Name
Relationship
Phone Number
Insurer
Case Manager
Claim Number
Medicare Number
Health Care Card
Pensioner Card
Do you identify as:
Aboriginal
Torres Strait Islander
Both
Neither
I CONSENT TO THE FOLLOWING:
Workcover and Motor Vehicle Accident Claimants: I acknowledge that I am responsible for payment of all accounts associated with the treatment of my injury if my insurer or employer suspends or discontinues payments.
Specialist Plus recording and sharing information obtained from me: I understand that this information may be shared with laboratories, radiological facilities, other health service providers, rehabilitation consultants, insurers, medical defence organisations, lawyers, or my employer for the purpose of investigation, treatment, and rehabilitation of my injury or illness, unless otherwise specified. I understand that I may revoke this consent at any time in writing.
Appointment Cancellations: I understand that if I do not notify the clinic of a cancellation at least 48 hours in advance, I will be charged a cancellation fee.
Medical Records Access: I authorise and consent for Specialist Plus to obtain copies of all imaging results, test results, and reports related to my injury.
Use of AI Technology in Consultations: Some doctors may use AI technology during consultations to assist with documentation. This software functions solely as a transcription tool and does not store any audio or recordings. If you have any concerns, please speak with the doctor or staff.
Name
Signature (type full name)
Date
Medical History
Are you right or left-handed?
Date of injury / illness
Location
Brief description of the event
Briefly explain what problems and symptoms you are currently having.
Description of injury or injuries (please use diagram to indicate where you feel pain – please include ALL affected areas)
Please mark on the diagram the site of pain. Also mark your worst pain with an ‘x’ and mark any numbness with an ‘o’.
Mark type:
X
O
Clear X
Clear O's
Investigations
Please tick (✓) if you have had the following investigations for current injury and list approximate dates
X-rays
CT Scan
Bone Scan
MRI
Ultrasound
Nerve Studies
Blood Tests
Other
Medications (please list names and dosages)
Add row
Reset
Past Medical History & Any Surgeries
Add row
Reset
Are you allergic to anything?
If yes, please list them below.
No
Yes
Pre-injury Job and Duties
Job Title
Employer
Hours per week
Please describe your pre-injury job duties and how do you do it
Are you currently off work?
Are you currently on work restrictions?
Reduced hours?
If so, please explain below (include hours, work restrictions specified by doctor and description of duties)
Education and Personal History
Were you born overseas? If yes, where?
What level of school did you complete?
Have you obtained further qualifications? If so, please list them below
Last 5 job positions (Briefly)
Where and when did you work in your last 5 years? Please include periods of unemployment or study.
Add row
Reset
Lifestyle
Are you a smoker?
If so, please indicate how much
Do you drink alcohol?
If so, please indicate how much
Consent
Name
Signature (type full name)
Date
Submit
