New Patient Registration - Edgecliff Physiotherapy Sports & Spinal Centre

Title

Name*

First Last

Email Address*

Date of birth*

Address*

Street Address Suburb Postcode

Contact numbers (home phone & mobile)*

Next of kin (In case of emergency)*

Contact number*

General practioner name*

Contact number*

Address

Street Address Suburb State Postcode

Are you in a private health fund?

Yes
No

Name of health fund

How were you referred to us?

**Please bring your referral to your first appointment**

GP / Specialist details (name, addess and phone number)

Please list any other medical conditions that we should be aware of.

Do you consent to your physiotherapist communicating with your referring doctor/general practitioner or case manager?

Yes
No

Do you have an implanted cardiac pacemaker?

Yes
No

How will you be paying?

Cash
Visa / Mastercard
Eftpos

Veterans

DVA - Gold or White card - please select

Gold
White

DVA Number

Expiry date

Workers Compensation or Third Party Insurance

Insurance Company

Address

Street Address Suburb State Postcode

Claim number

Date of injury

Employer

Case Manager

Phone

Fax

Terms and Conditions

If I am unable to attend my appointment, I will give at least 12 hours notice of my cancellation.

Payment is due at the time of consultation.

I understand that if my account is overdue, I will be invoiced accordingly.

Any accounts which are not settled by the end of the month will incur an additional administration fee of $10 for every month overdue.

Any outstanding accounts requiring us to use a recovery agent will incur further additional processing charges.

To claim through workers compensation, we will need your employer’s details, insurance details and claim number (please see front of sheet).

Any missed appointment/s without cancelling may incur a charge of $35/$40 (depending on the physiotherapist).

Any information on this form will not be disclosed to any other parties.

I have read and agree to the above conditions.*

Yes

Comments

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