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(02) 9971 1188

Sydney Academy of Sport & Recreation,
Wakehurst Parkway, Narrabeen 2101

Sports Physicians
Sports Medicine Registrars
- Dr. David Jefferies
Orthopedic Surgery
- Knee – Dr. Justin Roe
- Hip & Knee – Prof Bill Walter
Sports Podiatry
- Mr. Muhammad (Mo) Maarj
- Mr. Michael Gumatay
Paediatric Rehab / Sports Medicine
- Paediatric Rehabilitation –
  Dr. Louise Tofts
Massage & Nutrition
- Massage – Tina Falco
Neurosurgery
- Dr. Nicholas Little

Sports Physicians
Sports Medicine Registrars
- Dr. David Jefferies
Orthopedic Surgery
- Knee – Dr. Justin Roe
- Hip & Knee – Prof Bill Walter
Sports Podiatry
- Mr. Muhammad (Mo) Maarj
- Mr. Michael Gumatay
Paediatric Rehab / Sports Medicine
- Paediatric Rehabilitation –
  Dr. Louise Tofts
Massage & Nutrition
- Massage – Tina Falco
Neurosurgery
- Dr. Nicholas Little

Sports Medicine Patient Information Form

Important Privacy Notice

Information collected by us about you will be stored according to requirements of Federal Privacy legislation. lt will only be passed on where appropriate to the care of the medical problem about which you consulted us (e.g. to your physio or local doctor), or where legally required. lf you require more information, ask a staff member or your treating doctor.

Please fill in all fields or use “n/a” where not applicable.

Click here to download a PDF version to print.

Title *

Mr
Mrs
Miss
Ms
Dr

Name *

First

Last

Address *

Suburb & Postcode *

Date of Birth *

Age *

Occupation

Phone Number *

Email

Medicare Number *

Ref. No. next to name *

Parent's Name (if child)

Parent's Medicare Ref No

Parent's DOB

GP's Name

Physiotherapist Name

Referred By

Referrer Name

Private Health Fund

Number

Ref

Dep Veteran Affairs No

Expiry

Workers Compensation Claim / Third Party Claim *

Yes
No

Date of injury

Claim Number

Insurance Company

Address

Case Manager

Case Manager Phone No.

Exercise (list Sport/Activity - Frequency & Duration - Position Played - Coach) *

Are you likely to be drug tested in your sport? *

Yes
No

Do you take any medications? List below. *

Do you have any illnesses? lnclude the conditions your medication treats. *

Have you had any surgical procedures? List procedures and dates. *

Do you have any medical allergies? *

Does your family have any illnesses that follows generations? *

Please summarise your problem including dates and main issues you are wanting to rectify. *

Do you have any previous significant injuries? *

How did you hear about us?

Acknowledgement *

The above information is correct to the best of my knowledge. I have read the privacy notice above. I underdtand that I will be personally responsible for my accounts .

Phone

Your Appointment

Getting Here

FAQ

Services

Patient Info Form

Contact

Narrabeen Sports and Exercise Medicine Centre

Sydney Academy of Sport & Recreation, Wakehurst Parkway, Narrabeen NSW 2101

(02) 9971 1188

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Appointments

Please note that a GP referral is required in order to qualify for a Medicare rebate with all specialists Doctors. Referrals from Allied Health providers cannot be used in place of a referral from a GP. Referrals are not required for podiatrists.

Call us on (02) 9971 1188 for more information

Sports Med Topics

Plantar fasciitis: Top Exercises for Recovery
Recommended sports shoes (September 2020)
Operational Plan in Response to the Medical Emergency Presented by the COVID-19 Pandemic
Posterior Tibial Tendon Dysfunction (PTTD)
Radial Shock Wave Therapy – A treatment for tendons

We acknowledge the Traditional Custodians, the Gayamaygal and Garigal peoples and their Country on which we run our clinics. By these words we show our respect to all Aboriginal people. We acknowledge Elders past, present and emerging and the spirits and ancestors of the Clans that lived in this area.