New Patient Registration

Your details

Title *

First name *

Surname *

Preferred name (if different from above)

Date of birth (DD/MM/YYYY)

Home phone

Work phone

Mobile phone

Email

Address

Suburb

Occupation

Presenting problem: *

If you have had investigations, Where were they taken? (N/A for none)

Date of injury

Date of surgery (if applicable)

Name of surgeon (if applicable)

Referring doctor

Name and clinic of your GP? (N/A if none) *

Parent or guardian details (if applicable)

Parent or guardian name

Home phone

Mobile phone

Work phone

Email

Are you a pension/concession card holder? *

Yes

No

Which account type will you be paying with today?

Medicare details *

Workcover details

Workcover Claim Number

Insurer

Employer *

Employer Contact Person

Employer Phone *

Employer Email

TAC details

TAC Claim Number

Date of Injury *

DVA Card *

Gold Card

White Card

DVA Number *

How will you be paying today? *

Details of person responsible for payment of our invoices

As above

Different person

Name

Address

Address line 1

Address line 2

City

State

Post code

Phone

Private Health Fund (if applicable)

Membership number

Ref

Are you allergic to: *

Tapes

Massage creams*

Other (please specify)Other (please specify)

No Allergies

*The main ingredients of the massage cream we use are: Arnica montana, Hypericum perforatum (St John’s Wort) Calendula officinalis and Melaleuca alternifolia (Tea Tree Oil)

Do you have a pacemaker? *

Yes

No

Do you have a history of fainting? *

Yes

No

Do you have any other health concerns you would like your therapist to know about?

Please discuss any concerns with your therapist before commencing treatment.

Please note: Payment is expected at the time of service.

Non-payment of accounts will incur an additional fee of $10.00

TERMS AND CONDITIONS:
1. I agree to pay at the time of consultation unless an alternative arrangement has been made PRIOR to my appointment.
2. If payment is not received at the time of service, I understand a $5 administration fee may apply.
3. Outstanding accounts must be paid within 7 days, otherwise additional account processing fees may be charged.
4. Cheques can be made payable to Geelong Hand Therapy.
5. Credit card payments over the phone are accepted.
6. Medicare DOES NOT cover Occupational Therapy unless you have an Enhanced Primary Care (EPC) plan from your GP.

Checkboxes *

I understand the above terms and conditions and consent for my/my child's therapist to access and view any images i.e X-rays, ultrasound, MRI investigations related to my/my child's injury or condition, and to discuss my/my child's treatment with my/my child's referring GP or Surgeon

Name

Date

Signature

Clear

Your details

Parent or guardian details (if applicable)

Workcover details

TAC details

Please note: Payment is expected at the time of service.

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