Patient Details Form

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Please complete and submit this form prior to your consultation.

Appointment date *

YYYY

Surname *

First Name/s *

SA ID Number / Passport number as appropriate (please specify country of residence)

Date of Birth *

YYYY

Email *

Cellphone number *

Home telephone number

Work telephone number

Address *

Medical Aid Number

Medical Aid Name (please select "private" if you have no medical aid) *

Medical aid name if not on the above list.

Medical Aid Plan

Principal member of my medical aid.

Gap Cover *

Gap cover name if "Other" was selected above

Gap cover policy number

Health / travel insurance

Insurance policy details

Next of kin contact details. *

General practitioner (please select "No GP" if appropriate) *

Specialist physician (if any)

Medical conditions I suffer from, medications I am currently on (please answer "nil" as appropriate) *

I am on blood-thinning medications e.g. (but not limited to) Warfarin, Clexane, Xarelto, Plavix, Aspirin, Ecotrin. *

Yes

Please list the medications, dosage and last blood test results if you answered "yes" to the question above.

Name of any previous orthopaedic surgeon/s consulted about my current problem.

What body region is affected? *

Hip

Knee

Hand

Other:

Required

Duration of Symptoms *

Days

Months

Years

Other:

Required

Pain

Mild

Severe

Clear selection

Stiffness

Mild

Severe

Clear selection

Locking / clicking / snapping

Mild

Severe

Clear selection

Joint instability (feels like it wants to dislocate)

Mild

Severe

Clear selection

Pain down the leg / back pain

Mild

Severe

Clear selection

Loss of feeling / pins + needles

Mild

Severe

Clear selection

Weakness

Mild

Severe

Clear selection

Brief description of the traumatic event / development of the current complaint.

Which of the following digital* imaging investigations of the affected region have you had? (* the result was saved on a computer)

Xray

CT scan

MRI scan

Isotope bone scan

Ultrasound

Date of the latest investigation (month, year, description)

Where were the imaging investigations performed?

I give Dr Nick Martin permission to view my imaging investigations and to discuss them with a specialist radiologist. *

Yes

I agree that I will be invoiced invoiced for a specialist consultation of average duration ( 0190). The cost of the consultation is R 900 (discounted to R 800 on immediate settlement). Medical aid rates do not apply. Patients are required to submit the invoice to their medical aids as required. *

Yes

I can not afford your rates, please contact me in this regard.

How did you hear about us?

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