TRIAGE FORM | Cairns Orthopaedic Clinic

Private Fracture Clinic - Patient Triage Form

Please complete the following form and hit "submit" in order for the Doctor to triage your information and provide and appointment date.

* 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.