Patient Registration Form

Title

Given Name

Surname

Street Address

Suburb

Postcode

Date of Birth

Occupation

Phone Number

Private Health Insurance (Fund Name Only)

DVA Number (If Applicable)

TAC Number (If Applicable)

Work Cover Claim Number (If Applicable)

Are you on an Enhanced Primary Care Plan?
NoYes

GP Name

Referring Doctor / Specialist (If Applicable)

Referring Doctors / Specialist Practice (If Applicable)

Medical History

Current Medication

Emergency Contact Details:

How did yoy hear about Us?

If other, please say here

Informed Consent. By submitting this form

I give consent for treatment at Central Victorian Hand Therapy.
I agree to this consent remaining valid until such time as I withdraw my consent.
I also agree and give consent for my case to be discussed with interested parties such as my GP or referring doctor / specialist.
I understand that if I cancel within 24 hours or fail to attend an appointment I will be charged a $25 non attendance fee on the first occasion and full fee on any subsequent occasion
I understand that I am liable for all fees until my TAC or Workers compensation claim has been formally approved and a claim number supplied to CVHT

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