New Patient Form

Please complete this form before your first appointment.

First Name

Preferred name

Last Name

Date of Birth

Home address

Mobile Number

Medicare Card Number

Medicare Reference Number

Do you have a Commonwealth pension/health care card

Yes

Pension / Healthcare / Senior or DVA Card Number

Private Health Fund

Emergency Contact Name

Emergency Contact Phone

Relationship to you

Appointment with:

Dietitian

Physiotherapist

Speech Pathologist

Reason for appointment

We understand that unexpected issues can arise and you may need to cancel your appointment. We ask that cancellations are made at least 24 hours in advance. This allows your appointment time to be given to another patient. When a patient does not show up for their appointment without cancelling, other patients lose the opportunity to be seen.

Patients who repeatedly do not attend their appointments will be required to pay a cancellation fee. The cancellation fee is to be paid before future appointments can be made.

First failure to attend / late cancellation: you will be given a friendly reminder of the cancellation policy.
Second failure to attend / late cancellation: you will receive a letter and invoice for a $50 cancellation fee.

Please sign below to indicate you have read and understood the cancellation policy.

Signature of Patient or Guardian if under 16 years

Thank you.
We look forward to meeting you at your appointment.

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