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SMART OT REFERRAL FORM. Our records are entirely confidential.
First Name
Surname
Address
Suburb
Postcode
Email address
Date of Birthdd/mm/yyy
Home Phone
Work Phone
Mobile Phone
Occupation
Spouse/Next of Kin
Spouse/Next of Kin Contact
Doctor’s name
Doctor's Address
Referred By
Health Fundif applicable
Extraschoose one
Department of Veterans Affairs No.if applicable
Will this consultation be a Workcover claim?select one
Will this consultation be a Motor Acc claim?select one
If Yes, 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”***

MEDICAL HISTORY/CONDITION
0 /
REQUEST FOR SMART OT SERVICES: PLEASE LIST REASONS FOR SERVICES (ie. ADL pre-surgical home visit)
0 /

PAYMENT TERMS ARE 7 DAYS ON INVOICE. WE ACCEPT CASH, CREDIT CARDS AND EFTPOS. PAYMENT CAN BE MADE OVER THE PHONE 8293 1100 PLEASE ACKNOWLEDGE AND ACCEPT RESPONSIBILITY FOR PAYMENT OF ALL SESSIONS. I UNDERSTAND THAT THE INITIAL CONSULT FEE IS $175.00 AND WILL BE INVOICED TO THE CLIENT OR 

I Acceptselect one

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

I Acceptselect one
Dateof acceptance
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