Allied Health Patient Contact Details Form

allied health patient contact details form

First Name

Surname

Address

Suburb

Postcode

Date of Birthdd/mm/yyyy

Home Phone

Work Phone

Mobile Phone

Email address

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

Receive email?

YesNo

Occupation

Spouse/Next of Kin

Spouse/Next of Kin Contact

Doctor’s name

Doctor's Address

Referred By

Health Fundif applicable

Extrasselect one

YesNo

Department of Veterans Affairs No.if applicable

Will this consultation be a Workcover OR Motor Acc claim?

Claim?select one

YesNo

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

Yes

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

I doI do not

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