Make an Appointment

If you would like further information or if you wish to make an appointment with Dr Kaldas please contact his rooms listed or submit an enquiry using our contact email form below.

If you would like to arrange an appointment with our Physiotherapist, please also call the clinic on the above number.

 

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Personal Details
Title *
First Name *
Last Name *
Address *
Postcode *
Email Address *
Home Phone Number
Work Phone Number
Mobile Phone Number
What is your most preffered method of telephone contact? *
Next of Kin (Please provide two next of kin details)
Name *
Relationship *
Contact Number *
Name *
Realtionship *
Contact Number *
Claim Details
Medicare Number
Ref No
Exp Date
Private Health Insurance
Name
Fund Number
Concession Cards
Aged or Diability Pension Number
Exp Date
Dep Veterans Affairs Card Number
Card Colour
Exp Date
Workcover (if applicable)
Claim Number
Insurer
TAC Details (if applicable)
Date of Accident
Claim Number
GP Details
Usual GP Name *
Address *
Medical Questionnaire
Please list your regular medications including dose and frequency
If female – is there any chance you are pregnant
Sex *
Chief Complaints
Pain Areas
Current Pain Level *
Does the pain radiate anywhere (“shooting down” or “shooting up”) *
When was the pain started? *
How was the pain started? *
Please, describe your pain
Other
How often is your pain present? *
Worst time of day? *
Any colour change or temperature change? *
Numbness in anywhere? *
"Pins and Needles"? *
Weakness? (Right leg, right arm, both legs....) *
Swelling? *
What makes symptoms worse/exacerbate? *
Other
What makes the symptoms better? *
Medication (Names)
Other
Sleeping *
Past Medical History
Heart
Other
Lungs
Other
Gastrointestinal
Other
Kidney
Dialysis (When)
Other
Endocrine
Other
Neuro
Other
Psychiatric
Other
Bone / Muscular
Other
Cancer
Allergies
Latex *
Reaction
Contrast (Dye) *
Reaction
Allergic to any medication(s)?
Full Name *
Date *
* Required fields