New patient registration form - City

New patient registration form - City

Patient Registration Form Physiotherapy- Pitt Street /King Street

Title:_________First Name: _______________________Surname: ________________________

Address: _______________________________________________________________________
Suburb: _______________________________________ Post code: _____________________
Date of Birth: _____/_____/_____
Contact Numbers:
Home: _____________________ Work: _____________________
Mobile: ____________________ Fax: _____________________
Email Address: ___________________________________________________________
Occupation: ______________________________________________________________
Area Injured: _____________________________________________________________
Date of Injury: _____/_____/_____ Health Fund: __________________________
GP: _________________________________ Phone number: ______________________
Address: _________________________________________________________________
Relevant Medical History: __________________________________________________
Medication/ Allergies: ______________________________________________________
Is this a Workers Compensation Claim? Yes / No
Physical Activity: Time per week (e.g. 1 hour):
______________________ ______________________
______________________ ______________________

Referral Source: Word of Mouth: Y / N Name:________________________

GP/Specialist ______________________________________
Website: __________________________________________
Other: ____________________________________________
Cancellation Policy in accordance with the Australian Physiotherapy Association
Our practice requires 24 hours notice if you wish to cancel your appointment. This provides the practice with the opportunity to offer the appointment to other patients. If 24 hours notice is not provided and you do not attend, you may be charged a cancellation fee. Motor Accident Insurance and Workers Compensation does not cover charges for non attendance. These charges will need to be met by the patient.

 

Patient Signature:______________________________  Date: __/__/____

 

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Pitt St. City Practice

Address:
Level 7 60 Pitt Street Sydney 2000
Hours of Operation:
Mon - Fri 7:30am - 6:00pm
Telephone:
(02) 9251-5111

King Street Practice

Address:
Fitness First - The Zone / 94 King Street Sydney 2000
Hours of Operation:
Mon - Fri 7:30am - 6:00pm
Telephone:
(02) 9251-5111