Patient Contact Details Form

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First Name
Surname
Address
Suburb
Postcode
Date of Birthdd/mm/yyy
Home Phone
Work Phone
Mobile Phone

Do you wish to receive news from Smart Health training by email?

Receive email?
Occupation
Spouse/Next of Kin
Spouse/Next of Kin Contact
Doctor’s name
Doctor's Address
Referred By
Health Fundif applicable
Extrasselect one
Department of Veterans Affairs No.if applicable

Will this consultation be a Workcover OR Motor Acc claim?

Claim?select one
Claims Manager
Claim No
Which Insurance Company will the claim be lodged with?
***Please note that if your claim has not been approved you will need to pay for your consult on the day and seek reimbursement – there may be an “out of pocket expense”***

PAYMENT IS REQUESTED AT TIME OF SERVICE. WE ACCEPT CASH, CREDIT CARDS AND EFTPOS!

A 24 HOUR CANCELLATION NOTICE IS REQUIRED IF YOU’RE NOT ABLE TO ATTEND THE SESSION TIME OTHERWISE A PAYMENT IS REQUIRED FOR THE SESSION NOT ATTENDED. THIS WILL ENABLE OTHER CLIENTS TO USE THE ALLOTTED TIME. IF RUNNING LATE FOR YOUR APPOINTMENT, THE SESSION WILL BE SHORTENED SO THAT THE NEXT CLIENT IS NOT INCONVENIENCED.

PLEASE CHECK THE BOX TO ACKNOWLEDGE AND ACCEPT RESPONSIBILITY FOR PAYMENT OF ALL SESSIONS

I ACCEPT
I consent to Smart Health Training & Services obtaining and giving information, both verbally and in writing, to/from other Health Professionals pertaining to the medical conditions, where relevant, to the treatment being received at Smart Health Training & Services. These professionals may include your GP, Case Manager, Radiologist. Etc
Information Consentselect one
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