To be completed and signed by a guardian/parent if under the age of 18.
Required fields are noted with *

Your Personal Information

*Name

Date of Birth (dd/mm/yyyy)

Gender

Contact Details

Address*

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?

Self Referred
Referred by a doctor

Referring Doctor/Surgeon

Doctor's Name*

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*

Local Doctor's Address*

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?

Yes
No

Employer Details

*Name*

Address

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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Patient Registration

Your Personal Information

Contact Details

Referring Doctor/Surgeon

Veterans, Work Cover and Insurance

Brighton

Altona North

Morwell

Richmond

Drouin

Moorabbin

Heidelberg

Berwick

Wantirna

Richmond Bridge Road

Cabrini Malvern

Traralgon

Tullamarine

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