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New Patient Registration

Title
Name*
First Last
Email Address*
Date of birth*
Date Format: MM slash DD slash YYYY
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?
- GP
- Specialist
- Signage
- Relative / friend
- Yellow Pages
- Internet
**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
Date Format: MM slash DD slash YYYY
Workers Compensation or Third Party Insurance
Insurance Company
Address
Street Address Suburb State Postcode
Claim number
Date of injury
Date Format: MM slash DD slash YYYY
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
Name
This field is for validation purposes and should be left unchanged.

Information

Articles
FAQ
New Patient Registration

Hours

Monday to Thursday, 7:30am - 7:30pm
Friday, 7:30am - 5:00pm
Saturday mornings, by appointment only

Contact Us

Suite 505 Eastpoint Tower
180 Ocean Street, Edgecliff, NSW 2027
Phone: (02) 9326 1168
Fax: (02) 9328 7217

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© 2020 Edgecliff Physiotherapy Sports & Spinal Centre | PRIVACY POLICY

Edgecliff Physiotherapy is open for appointments at the practice
(while observing stringent hygiene measures)

We are also offering Telehealth video consultations,
home visits & online therapeutic exercise classes

Call us on 9326 1168 or
email info@edgecliffphysio.com.au