APPOINTMENT REQUEST (Old)

Online Booking Procedure

1. Complete the below form with the details required

2. Submit Form

3. Select Health Group Pty Ltd will be in contact to confirm appointment time. Please ensure the accuracy of your information.

– Should you not receive an appointment confirmation or prefer to just speak to a friendly voice then please call us on 82404577

FIRST NAME

SURNAME

Email Address

Phone Number

CONTACT METHOD - Preferred method of contact

SERVICE TYPE - Physiotherapy / Remedial Massage / Yoga

PATIENT TYPE - Private / Medicare / MVA / Return to Work

PATIENT STATUS - Have you been to see us before?

EPC - REFERRAL LETTER - Do you have an EPC Referral from your GP?

TREATMENT - Have you sort treatment from us in the last 6 months in relation to your condition?

CLAIM APPROVAL - Has your Claim been approved?

Name of insurer/claims agent?

What is your Claim #?

Date of Birth? (DD/MM/YYYY)

PHYSIO - Date - Preference #1

PHYSIO - Time - Preference #1

PHYSIO - Date - Preference #2

PHYSIO - Time - Preference #2

MASSAGE - Type

MASSAGE - Duration

MASSAGE - Date - Preference #1

MASSAGE - Time - Preference #1

MASSAGE - Date - Preference #2

MASSAGE - Time - Preference #2

YOGA - CLASS - Date & Time - Preference #1

Any Further Information - ie, request for a certain therapist or specific time?

PROMOTION/DISCOUNT - Do you have a promotion/discount voucher or code?

PROMOTION/DISCOUNT - Type

PROMOTION/DISCOUNT - Code

I have read and understood the Terms and Conditions. I have read and understood the Terms and Conditions. Terms & Conditions

15 + 12 =