NEW PATIENT FORM

First Name *

Last Name *

Date of Birth *

Gender

FemaleMale Other

CONTACT INFOMATION

Email Address *

Mobile Number *

Home Phone

Street Address *

City *

State *

Postcode *

MEDICARE INFORMATION

Medicare Card Number *

Medicare Reference Number *

Expiry Date *

VETERANS. WORK COVER & INSURANCE

Are you a Pension or Veteran card holder *

YesNo

Is your appointment a work-cover Claim? *

Yes No

Name of Employer

Employer Contact Name

Employer Email

Employer Contact Number

Employer Street Address

Employer City

Employer State

Employer Postcode

Employer Date of Inquiry

Insurer Name

Insurance Claim Number

Is this a TAC Related Enquiry? *

YesNo

TAC Claim Number

TAC Date of Accident

REFFERAL TO ACTION REHAB

How did you hear about us? *

Doctor/Surgeon's Name

Doctor/Surgeon's Practice Name

Doctor/Surgeon's Contact Number

Sports Club Name

School Name

Which Socials?

Instagram Facebook LinkedIn

So... How did you hear about us? ?

I agree to release the relevant medical information to the referring doctor and other health professionals involved in my care.
I agree to give 2 business days’ notice of any appointment cancellation or pay a $30 cancellation fee.
A cancellation fee will be charged personally to Workcover and TAC patients where 2 business days’ notice is not given.
I agree to pay all accounts within 7 days from the invoice date or a $20 administration fee will apply to each invoice.
I agree to pay any additional costs associated with any debt collecting and/or legal expenses applicable to my accounts.
I have read and agree to the fee policy.
I have been made aware of the Privacy Policy and Terms and Conditions

I have read and agree to the Action Rehab's Terms of Service above *