Patient Information Form

Personal Details

Medicare Card

EPC Referral:
Private Health Insurance

Dept of Veterans Affairs Card
DVA Card Colour:
Referring doctor

Family doctor

Emergency Contact

Worker's Compensation Claim

Appointment Details

I agree to be responsible for payment of all service rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service, unless other arrangements have been made. I understand that there are additional fees for dressings, orthotics, splints or other appliances provided to me as part of my treatment.

The clinic requires 24 hours notice for cancellation or changes to your appointment time. Should you fail to attend an appointment without reasonable notice you will be required to pay full consultation fee for the missed appointment before making further appointments. Workcover / DVA / EPC patients will be personally responsible for any appointments they fail to attend without giving the required notice. Please note: all Workcover patients require a current ‘Workers’ Compensation Medical Certificate’ covering hand therapy treatment.

Release of information: I consent to the exchange of information, documents and test results between my Occupational Therapist / Hand Therapist / Physiotherapist and other parties involved to enable the complete management of my condition, including Treating Surgeon / GP, Therapists, Insurance Companies.