PATIENT INTAKE FORM | Cairns Orthopaedic Clinic

Private Fracture Clinic - Patient Intake Form

IMPORTANT: A GP referral is not required for this clinic. Please self-refer using the below form or contact our rooms on (07) 4040 6200 Once you have completed the form hit "submit" in order for the Doctor to review your information and provide and appointment date via email.

* Mandatory fields

Given Name*

Surname*

D.O.B.*

Contact Phone Number*

Email Address*

Do you have private health insurance? (Please be advised Private Health insurance is not required)*

YesNo

What is the injury?*

When did the injury occur?*

How did the injury occur?*

Have you had any radiology/imaging done?*

YesNo

Toggle Next field if previous field yes

If yes, which radiology practice/hospital and when?*

What treatment have you had so far?*

Is this an open fracture or major trauma?*

YesNo

IMPORTANT - This is not an emergency service.

For open fractures, major trauma, or urgent medical concerns please attend your nearest Emergency Department or call 000.