Please call us on
1300 762 227
to book an appointment.
1300 762 227
About Us
Locations
Our Staff
Community
Work With Us
Join The Team
Refer To Us
Treatments
Sports Injuries
Work Related Injuries
Wrist Injury
Thumb Injury
Sprained Finger
Mallet Finger
Dislocated Shoulder Treatment
Scaphoid Fracture
Common Conditions
Children’s Conditions
Pregnancy and your hand
Arthritis Treatment
Massage
Urgent Care
Workshops
Group Sessions
Patient Forms
New Patient Registration
FAQs
Rebates
Make An Appointment
About Us
Locations
Our Staff
Community
Work With Us
Join The Team
Refer To Us
Treatments
Sports Injuries
Work Related Injuries
Wrist Injury
Thumb Injury
Sprained Finger
Mallet Finger
Dislocated Shoulder Treatment
Scaphoid Fracture
Common Conditions
Children’s Conditions
Pregnancy and your hand
Arthritis Treatment
Massage
Urgent Care
Workshops
Group Sessions
Patient Forms
New Patient Registration
FAQs
Rebates
Make An Appointment
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
Mr.
Mrs.
Miss
Ms.
Mst.
Prefix
First
Last
Date of Birth (dd/mm/yyyy)
Gender
Gender
Male
Female
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
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
Medicare Card Number
Medicare Reference
Medicare 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
I agree to release the relevant medical information to the referring doctor and other health professionals involved in my care.
I agree to give 2 business days’ notice of any appointment cancellation or pay a $30 cancellation fee.
A cancellation fee will be charged personally to Workcover and TAC patients where 2 business days’ notice is not given.
I agree to pay all accounts within 7 days from the invoice date or a $20 administration fee will apply to each invoice.
I agree to pay any additional costs associated with any debt collecting and/or legal expenses applicable to my accounts.
I have read and agree to the fee policy.
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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