PATIENT CONTACT DETAILS FORM. Our records are entirely confidential.
  • Surname*
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  • First Name*
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  • Address*
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  • Suburb*
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  • Postcode*
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  • Date of Birth*dd/mm/yyy
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  • Home Phone*
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  • Work Phone*
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  • Mobile Phone*
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  • Email address*
    9
  • Do you wish to receive news from Smart Health training by email?*select one
    Yes
    No
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  • Occupation*
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  • Spouse/Next of Kin*
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  • Spouse/Next of Kin Contact*
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  • Doctor’s name*
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  • Doctor's Address*
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  • Referred By*
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  • Health Fund*if applicable
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  • Extras*choose one
    yes
    no
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  • Department of Veterans Affairs No.*if applicable
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  • Will this consultation be a Workcover OR Motor Acc claim*select one
    yes
    no
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  • Claims Manager*
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  • Claim No*
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  • Which Insurance Company will the claim be lodged with?*
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  • ***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”***
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  • PAYMENT IS REQUESTED AT TIME OF SERVICE. WE ACCEPT CASH, CREDIT CARDS AND EFTPOS!
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  • 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.
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  • PLEASE CHECK THE BOX TO ACKNOWLEDGE AND ACCEPT RESPONSIBILITY FOR PAYMENT OF ALL SESSIONS.*
    I ACCEPT
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  • 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
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  • Information Consent*select one
    I do
    I do not
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