New Patient Form – Dr Robert Simons Medical Practice

Please advise Dr Simons Rooms if you have:

a) travelled overseas within the last 14 days ;
b) have cold or flu like symptoms or
c) been in contact with a confirmed corona virus case.

Full Name

As it would appear on your medicare card

Email Address

Mobile or Phone Number

Date of Birth

DD/MM/YYYY

Address

Occupation

Height

Weight

Medicare Number

Reference No on Card

Expiry Date

MM/YYYY

Who Referred You to Dr Simons?

Is Your Enquiry Related to Stem Cell Treatments?

Yes

Describe your Primary Problem

When did it Start?

Is the Pain a Result of an Injury?

If so, describe briefly

When Does Your Pain Occur

At Rest

With Use

Is it Worse for;

Sitting

Standing

Walking

Bending

Night in Bed

Describe Your Pain

Sharp

Dull

Achy

Deep

Burning

Throbbing

Rate Your Pain Level Overall from 1 to 10. 1 Being Very Mild to 10 Being Extreme

Have You Consulted any Specialists. Chiropractors or Physiotherapists with your Condition?

If yes, please provide details

Since this Problem Started, What Radiology has Been Done?

X-Ray

MRI

Scan

None

Please email reports of Radiology relating to your condition. Please note those who provide reports will be prioritised in relation to scheduling appointments.

If Radiology was Done, Please Advise which Radiology Company (i.e. SKG, Perth Radiology)

Have You had any Pathology Blood Tests Done?

If so, briefly describe the findings

List Current PAIN Medication

List Other Current Medications and Supplements

What Kind of Exercise do You Participate in?

Are You Allergic to any Medication or Medical Supplies?

I.e. latex, tapes, etc.

Do You Have any Concurrent Health Issues?

If so briefly describe

Payment
Initial consultation fee is $340.00 plus an additional fee of $150 – $300 for injection treatment on the day. Dr Simons may use the ultrasound, this cost is between $55 – $110. Subsequent 20 minute Consultation fees are $130.

Please Note:
We are not a bulk billing practice and accounts for services and supplements must be settled at the end of your consultation.
The consultation fee and Ultrasound are claimable through Medicare.
Dr Simons does NOT treat patients in relation to Workers Compensation or Insurance Claims.

We accept Visa, Mastercard, EFTPOS, cash.

Patient Information

We will remind you of your appointment 48 hours in advance via SMS on your mobile phone, if this is not confirmed by yourself 24 hours prior your appointment time your appointment will be cancelled.
If you do not attend a confirmed appointment a cancellation fee $120 will apply.Please do not wear any perfumes or aftershave as some of our patients are very sensitive to chemicals.We appreciate your understanding that we have a busy reception desk and request, to ensure accuracy, that all enquiries about treatment, supplements and any other questions for the doctor to be placed in writing via email, fax or post.

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