Patient Registration Form

Please complete at least one contact phone number.

Workers Compensation (if applicable)

FINANCIAL INFORMATION

Medicare does not completely cover the cost of your consultation.

It is a term of the provision of these services that the patient shall be liable for all debt collection fees and charges, including but not limited to agent fees, solicitor costs and disbursements in the event that the collection is required. Other fees apply for Workcover.

In the event that a Workcover claim is rejected, it is the patients full responsibility to cover the costs of the consultations. Other fees may be incurred for fractures and their management.

It is practice policy that we do not see or treat Third Party or Public Liability cases. Should you wish to change your status from private to Third Party or Public Liability claim for this injury then you treatment will not continue. Under no circumstances will Medico-Legal reports be provided.

CONSENT

I understand that payment of the account in full is my responsibility. I consent to the release and communication of information from or to any other medical provider for the purpose of my ongoing clinical management, ongoing clinical research and audit. Privacy Act (2000) details available upon request.