New Patient Registration | Hand & Upper Limb Centre

New Patient Registration

We require you to complete a Patient Information Form prior to your initial consult.

You can complete this online by filling out the form below, or in our office by arriving 10 minutes early to your appointment.

Preferred Contact Method?
Do you have Private Health Insurance? Yes No
Aged Pension Number? Yes No
Veterans Affair? Yes No


Did Your Accident Happen in WA?
Yes No
From time to time we conduct a patient satisfaction survey to assist us in evaluating our services. This may be an email survey from ourselves or an anonymous, internet based survey. May we include you or follow up?
Yes No
I consent to the information contained in this form being shared with the HAND AND UPPER LIMB CENTRE for relevant treatment and/or research purposes.
Yes This confirmation allows us to collect this information from you for the primary purpose of providing quality health care. The information will also be used for administrative, billing and debt collecting purposes, and for referrals and requests regarding your healthcare and you are authorising us to release said information to relevant referral parties ( including, employer, insurance company and rehabilitation provider ). Your information may be used for research and educational purposes, In which your confidentiality will be maintaned. This may include photos and / or videos. Please note that a 15% accounting fee may be charged on all overdue accounts.
How Did You Hear About Us?

Thanks! someone from our team will be in contact with you shortly.

Woops! your missing some information.