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PATIENT CONTACT INFORMATION FORM (Medical)

Our records are entirely confidential.

Title:
Surname
First Name
Middle Name
Preferred Name
DOB
Birth Sex
Gender Identity
Ethnicity
Address
0 /
Suburb
Postcode
Postal Address
0 /
Home Phone
Work phone
Preferred Contact Method
Mobile No
Email address
Consent to Email
Medicare No
Expiry Date
IRN
Pension/HCC No
Expiry Date
DVA No
Past Medical History
0 /
Pension Card Type
Gold/White/Orange:
Safety Net No
Health Ins Fund
Health Ins No
Head of Family: ( for under 18)
Next of Kin
Phone No
Phone No
Emergency Contact
Occupation
Will this consultation be a WorkCover OR Motor Accident claim?
If Yes, Claims Manager
Claim No
Which Insurance Company will the claim be lodged with?

Please note thatif your claim has not been approved you will need to pay for your consult onthe day and seek reimbursement.

There may be an“out of pocket expense”. please turn over …..

PAYMENT ISREQUESTED AT TIME OF SERVICE. WE ACCEPT CASH, CREDIT

CARDS AND EFTPOS!

A 24 HOURCANCELLATION NOTICE IS REQUIRED IF YOU’RE NOT ABLE TO

ATTEND THESESSION TIME OTHERWISE A PAYMENT IS REQUIRED FOR

THE SESSION NOTATTENDED. THIS WILL ENABLE OTHER CLIENTS TO USE

THE ALLOTTEDTIME. IF RUNNING LATE FOR YOUR APPOINTMENT, THE

SESSION WILL BESHORTENED SO THAT THE NEXT CLIENT IS NOT

INCONVENIENCED.

PLEASE CHECK THEBOX TO ACKNOWLEDGE AND ACCEPT

RESPONSIBILITYFOR PAYMENT OF ALL SESSIONS.


I consent toSmart Health Training & Services obtaining and giving

information, bothverbally and in writing, to/from other Health Professionals

pertaining to themedical conditions, where relevant, to the treatment being

received at SmartHealth Training & Services. These professionals may

include your GP,Case Manager, Radiologist. Etc

InformationConsent *select one

I consent
Do you wish to receive news from Smart Health training by email.
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