New Patient Form

GENERAL INFORMATION

MrMrsMissMs

First Name *

Surname *

Address *

Suburb *

Postcode *

Date of Birth *

Person responsible for payment *

YourselfParent

CONTACT DETAILS

Mobile Phone *

Home Phone

Email Address *

FAMILY GP / SPECIALIST DETAILS

Dr Name

Clinic Name

Phone Number

Were you referred by a specific doctor or health professional to this clinic?

YesNo

Please specify who?

Was a practitioner at FAARA recommended to you?

YesNo

Please specify practitioner

EMERGENCY CONTACT INFORMATION

Name *

Relationship *

Contact Number *

HOW WERE YOU REFERRED TO US?

Other please specify

EXTRA INFORMATION

Do you have Private Health Insurance? *

YesNo

Do you have DVA Card? *

Gold CardWhite Card

Card Number *

Which fund?

Medicare Number

Ref no.

Expiry Date

TAC

Date of Injury

Claim Number

WORKCOVER

Claim Number

Date of Injury (DOI)

Insurance Company

Employer Phone Number

All clients are responsible for payments of their invoices in full. We do not invoice Worksafe Insurers, TAC or your employer.

NDIS

Plan Type

Plan Managed Self Managed

FOR ALL PATIENTS

We require that your account be paid on the day of service. Please be advised that FAARA does not take responsibility for Health Funds being down or any HICAPS issues that may hinder the clinics ability to claim on the day (this includes cards that we are unable to swipe).

CANCELLATION POLICY

Please note, for any non-attended appointment without notification will result in the patient being billed a $20 cancellation fee.

We require 24 hours notice when cancelling and/or rescheduling.

Thank you for your co-operation.

PRIVACY NOTICE

Your personal Health Information and your Health Record may be collected, used and disclosed for the following reasons:

For communicating relevant information with other treating practitioners, general practitioners, specialists or allied health professionals
For follow up reminders, recall notices, notifications and information relating to FAARA
For National/State or Territory registers, reminder systems or disease notification as required by law
Accounting/Medicare/Health Insurance procedures
Quality Assurance activities such as accreditation
For disease notification as required by law (e.g. infectious disease)
For legal related disclosure as required by a court of law (e.g. subpoena, court order, suspected child abuse)
For research purpose (de-identified, meaning you are not able to be identified from the information given).

If you have any concerns or wish to restrict access to your personal health information please discuss this with your physiotherapist or receptionist. This practice adheres to National Privacy Principles ( www.privacy.gov.au).

Please sign below to indicate you are aware of our payment, cancellation policy and privacy notice.

Signature *

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Date *