About Brispine

Book an appointment

Step 1 - Patient Details
Step 2 - Pain Diagram
Step 3 - Everyday Pain

Before an appointment time is arranged, we need to better understand your problem as this Practice gives priority to urgent problems. Please assist by:

Completing the Pain Diagram as part of this three (3) step form process, and
Returning the following to us:
- Your GP referral letter
- X-rays and scans of our spine OR x-ray report

The forms, referral and X-rays may be posted or delivered to the above address or uploaded in the form.

When your information is received, it will be reviewed by Dr Williams. This process may take 4-5 working days. You will then be contacted with an appointment date and time and your information will be held here in readiness for your Initial Consultation. NB Until all your information is received, your request will not be processed.

Please do not call prior to this as your appointment time will not be available.

Thank you for your co-operation and understanding.

* Required

How long have you had back pain?	How long have you had leg pain?
Using the below diagrams please indicate on a scale of 1 - 10 (10 being the most painful) the level of pain felt in specific areas.
Left Shoulder Back Neck Shoulder Blade Left Lower Back Left Left Buttock Outside Arm Left Back Inside Arm Left Back Outside Leg Left Back Inside Leg Left Back Left Heel Right Shoulder Back Outside Arm Right Back Inside Arm Right Back Outside Leg Right Back Inside Leg Right Back Middle Back Shoulder Blade Right Lower Back Right Right Buttock Central Lower Back Right Heel Left Shoulder Right Chest Outside Leg Left Inside Leg Left Inside Arm Left Outside Arm Left Left Toes Left Chest Right Shoulder Outside Leg Right Inside Leg Right Inside Arm Right Outside Arm Right Right Toes

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First Name *	Last Name *
Email Address *	Phone Number *
Occupation *	Date of Birth *
Postal Address *	Suburb *
State *	Postcode *
Medicare Number	Medicare Reference Number
Medicare Expiry date
Do you have private health insurance? * Yes No
If yes, Health Fund Name
Health Fund Number
Is this a work cover claim? * Yes No
WorkCover Number
Case Manager Name
Case Manager Contact Phone Number
Is this an insurance claim from a third party (ie motor vehicle accident)? * Yes No
Insurance Company Name and Claim Number
Are you a DVA Patient? * Yes No
DVA Number
What sort of card do you have? Gold Card White Card
Do you have a GP referral? * Yes No	Have you had either an x-ray, a CT scan or an MRI scan? * Yes No
Please contact your local GP to arrange for an x-ray or a CT scan.
Please contact your local GP to arrange a referral.
How will you be supplying the GP referral and X-ray/CT/MRI report? I will upload GP referral and X-ray/CT/MRI report I will post in the forms
Upload GP Referral
Upload X-ray/CT/MRI report

About Brispine

Book an appointment

Latest News

Brisbane private extends a helping hand

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About Brispine

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Latest News

Brisbane private extends a helping hand

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My Condition

My Treatment

My Recovery

General