GOOD BONES ORTHOPAEDICS LTD

Julian Stoddart

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PHONE 06 769 5634

Request An Appointment

We may need to send you information in the post

We need these details if we are lodging claims for ACC

Name: Enter Name

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Email: Enter Email or write 'none'

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Home Address: Enter Address

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City / Town: Enter City

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Cell Phone: Enter Phone Number or write 'none'

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Home Phone: Enter Phone Number or wtite "none"

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Work Phone: Enter Phone Number or write 'none'

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Prefered Contact Number

Home Phone

Mobile Phone

Work Phone

Date of Birth: Enter Date of Birth

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Who is Referring You:

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Physiotherapist

Doctor

Other

Name of Referrer or Referrers Practise: Enter the Name of Your Referrer / Practice

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Where Have You Had X-Rays:

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Fulford Radiology (Base Hospital / Medicross / Phoenix / Stratford / Hawera)

Absolute Radiology

Advance Radiology (CareFirst)

Have not had x-rays / Out of town

The MAIN Area We are Seeing You About:

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Hip / Thigh

Knee / Leg

Ankle / Foot

What Side:

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Right Side

Left Side

Both Sides

Are You An ACC Case:

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Yes (you have an ACC number)

ACC Number: Enter ACC Number

Date of Injury: Enter Date of Injury

Do You Have Private Health Insurance:

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Yes

Message: Enter Additional Information That You Think May Be Helpful

Your Family Doctor or Practise: Enter Your Family Doctor or Practise Name

We need to know who you are

We need to be able to contact you

Please indicate your preferred daytime contact by ticking the appropriate circle

We need to contact the referrer for details of your condition

Complete These Questions if You are an ACC Case Otherwise Leave Blank

Knowing what we are seeing you for helps us prepare for you appointment

All patients require up to date x-rays (normally within the last 6 - 12 months)

If you are ACC patient your visit is paid for

Knowing if you are insured helps us with administration

We need to know who your GP (family doctor) is. Enter "None" if you dont have one