Please call us on 1300 762 227 to book an appointment.

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About Us
- Blog
- Locations
- Our Staff
- Community
- Work With Us
  - Join The Team
Treatments
Urgent Care
Workshops
- Workshops
- Group Sessions
Referrers
- Refer To Us
Patient Forms
Make An Appointment
Telehealth

Patient Registration

Home » Patient Information » Patient Registration

To be completed and signed by a guardian/parent if under the age of 18.
Required fields are noted with *
Your Personal Information
*Name
Prefix First Last
Date of Birth (dd/mm/yyyy)
Gender
Contact Details
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home
Work
* Email*

(This is our best way of communication so please ensure you fill in the email address)
Mobile
How did you find us?
How did you find us?
- Self Referred
- Referred by a doctor
Referring Doctor/Surgeon
Doctor's Name*
First Last
Doctor's Address
Referring Doctor's Phone
Is this doctor also your local doctor?
Is this also your local doctor?*
- Yes
- No
Local Doctor Details
Name of Local Doctor*
First Last
Local Doctor's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Local Doctor Phone
Medicare Information
Medicare Card Number*
Medicare Reference*
Medicare Expiry Date (mm/yyyy)*
Veterans, Work Cover and Insurance
Are you a Pension or Veteran Card Holder:
Are you a Pension or Veteran Card Holder?
- Yes
- No
Card Number
Expiry Date (mm/yyyy)
Is this a WorkCover claim?
Is this a WorkCover claim?
- Yes
- No
Employer Details
*Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Employer Phone
Employer Contact Person
Employer Date of Inquiry (dd/mm/yyyy)
Insurance Details
Insurer
Insurance Claim Number
Insurance Case Manager
Insurance Date of Surgery (dd/mm/yyyy)
Is this a TAC related enquiry?
is this a TAC related enquiry?
- Yes
- No
TAC Details
TAC Claim Number
TAC Date of Accident (dd/mm/yyyy)
TAC Date of Surgert (dd/mm/yyyy)
Conditions
1. I agree to release the relevant medical information to the referring doctor and other health professionals involved in my care.
2. I agree to give 2 business days’ notice of any appointment cancellation or pay a $30 cancellation fee.
3. A cancellation fee will be charged personally to Workcover and TAC patients where 2 business days’ notice is not given.
4. I agree to pay all accounts within 7 days from the invoice date or a $20 administration fee will apply to each invoice.
5. I agree to pay any additional costs associated with any debt collecting and/or legal expenses applicable to my accounts.
6. I have read and agree to the fee policy.
7. I have been made aware of the Privacy Policy.
*
- I have read and agree to the Action Rehab's Terms of Service.
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Altona North

Circle Health
6/230 Blackshaws Road
Altona North VIC 3025
1300 762 227

Moe

Clearview Radiology,
34 George Street,
Moe VIC 3825
1300 762 227

Richmond

Orthosport Victoria
Level 5, Epworth Hospital
89 Bridge Road
Richmond VIC 3121
1300 762 227

Drouin

Suite 13,
22-26 Princess Way
Drouin VIC 3818
1300 762 227

Moorabbin

Holmesglen Private Hospital
Private Consulting Suite 1
14/490 South Road
Moorabbin VIC 3194
1300 762 227

Heidelberg

Martin Medical,
Level 7, 10 Martin Street
Heidelberg VIC 3041
1300 762 227

Berwick

Epworth Specialist Suites
48 Kangan Dr
Berwick VIC 3086
1300 762 227

Wantirna

Knox Health and Sports Clinic
171 Stud Road
Wantirna VIC 3152
1300 762 227

Richmond Bridge Road

Melbourne Hand Surgery
549 Bridge Rd
Richmond VIC 3121
1300 762 227

Cabrini Malvern

Cabrini Medical Centre,
Suite 31,
Isabella Street
Malvern VIC 3144
1300 762 227

Traralgon

Gippsland Osteopathy and Sports Medicine Clinic
63 Argyle Street
Traralgon VIC 3844
1300 762 227

Tullamarine

Action Rehab C/- Sonic HealthPlus
Unit 1,
35-37 Tullamarine Park Drive
Tullamarine VIC 3043
1300 762 227