New Patient Registration

New Patient Registration

Your details

Have you had any investigations? (X-Ray, Ultrasound, MRI) *
If Yes, Where were your investigations taken?
Did you attend Emergency? *
Which Emergency hospital?
Are you a minor? *

Parent or guardian details

Are you a pension/concession card holder? *
EPC / GP Management Plan? *
Workcover claim? *

Workcover details

TAC claim? *

TAC details

Private health insurance? *
Department of Veteran Affairs *
DVA Card *
Are you allergic to: *
*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? *
Do you have a history of fainting? *
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.

Details of person responsible for payment of our invoices
Address
Address
Address line 1
Address line 2
City
State
Post code
How will you be paying today? *

Agreement and Consent

Consent *

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