New Patient Information Sheet
ADVERTISEMENT
1NEW PATIENT INFORMATION
Patient Personal details
Name
DOB
/
/
Address
City
State
Postcode
Mobile Phone
Home phone
Work Phone
Email
Gender
Male ⃝ Female ⃝
Occupation
Emergency
Phone
Contact
Body part needing treatment:
Healthcare Details
Medicare Number if
applicable
Ancillary (extras) Cover
Yes ⃝ No ⃝
Health Fund
Name of GP
Phone
Clinic Address
Account Details
(Please note all accounts are to be settled at the time of consultation unless otherwise agreed prior to your appointment)
□
I will be paying for my account privately
□
I have a pension/concession Card, Number: ___________________________ Expiry: ___/___/___
□
This is an approved Workcover Claim – Complete Section on other side
□
This is a TAC approved Claim – Complete section on other side
How did you hear about us?
□
Doctor: Name
□
Friend/Family Member
□
Workplace
□
Passing By
□
Advertisement: Where?
□
Web/Facebook/Internet
□
Other – Please specify?
Privacy Policy: We are required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and
privacy practices with respect to your health information. A copy of this policy is available at reception or on our website. If you have questions
about any part of this notice or if you want more information about your privacy rights, please don’t hesitate to ask.
I acknowledge that the information provided above to be true and correct as of today’s date.
Signature of Patient
Date: ___/___/__
(Or Guardian if under 18 years Old)
Located at Newtown Allied Health Centre, 309 Pakington Street, Newtown VIC 3220
Ph. (03) 52 212919, Fax: (03) 52 213394
Email: .au
Like us on Facebook
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical