FORM – New Patient

TITLE TITLEMr.Mrs.Miss.Ms.Mstr.Dr.Mx.

GIVEN NAMES

SURNAME

PREFERRED NAME PREFERRED NAMESame as Given NameOther

PREFERRED NAME

DATE OF BIRTH - (DAY) DATE OF BIRTH - (DAY)01020304050607080910111213141516171819202122232425262728293031

DATE OF BIRTH - (MONTH) DATE OF BIRTH - (MONTH)JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

DATE OF BIRTH - (YEAR - YYYY)

Email Address

Phone Number 1 Phone Number 1MOBILEHOMEWORK

Phone Number - MOBILE

Phone Number - HOME

Phone Number - WORK

Phone Number 2 Phone Number 2MOBILEHOMEWORKNot Applicable

Phone Number - MOBILE

Phone Number - HOME

Phone Number - WORK

Phone Number 3 Phone Number 3MOBILEHOMEWORKNot Applicable

Phone Number - MOBILE

Phone Number - HOME

Phone Number - WORK

POSTAL ADDRESS POSTAL ADDRESSRESIDENTIALPO BOX

HOUSE/UNIT #

STREET NAME

SUBURB

POST CODE

STATE STATESAACTNSWNTTASQLDVICWA

PO BOX NUMBER (Number Only)

PO BOX SUBURB

STATE STATESAACTNSWNTTASQLDVICWA

PO BOX POST CODE

CONTACT METHOD - Preferred method of contact CONTACT METHOD - Preferred method of contactEMAILPHONE CALLTEXT MESSAGE (SMS)

OCCUPATION

CONCESSION CARD - Are you a Concession Card Holder? CONCESSION CARD - Are you a Concession Card Holder?YESNO

CONCESSION CARD - Which card do you hold? CONCESSION CARD - Which card do you hold?Pension Concession CardHealth Care CareStudent - School (Rec to 12)Student ID - Tertiary (UNI, TAFE etc)Seniors Card

CONCESSION CARD - NUMBER

CONCESSION CARD - EXPIRY DATE (DD/MM/YYYY)

EMERGENCY CONTACT - GIVEN NAME

EMERGENCY CONTACT - SURNAME

EMERGENCY CONTACT - RELATIONSHIP TO PATIENT EMERGENCY CONTACT - RELATIONSHIP TO PATIENTParentSpouse / PartnerSiblingRelativeCarerFriendOther

EMERGENCY CONTACT - PHONE #

GENERAL PRACTITIONER - Doctors Name

GENERAL PRACTITIONER - Doctors Location GENERAL PRACTITIONER - Doctors LocationTrinity / Westcare Medical CentreOther

GENERAL PRACTITIONER - Doctors Clinic / Location / Address

PATIENT STATUS - Have you been to see us before? PATIENT STATUS - Have you been to see us before?YES - Existing Patient/Client of Select Health GroupNO - This is my first time

PRIVATE HEALTH - Do you have Private Health Insurance Extras Cover? PRIVATE HEALTH - Do you have Private Health Insurance Extras Cover?YESNO

PRIVATE HEALTH - If Yes, which Private Health Insurer? PRIVATE HEALTH - If Yes, which Private Health Insurer?BUPAHCFAAMIACA HEALTHADF FAMILY HEALTHAHMAPIAAUSTRALIAN UNITYCBHSCUA HEALTHDEFENCE HEALTHHBFHEALTH PARTNERSHIFMEDIBANKNAVY HEALTHNIBPHOENIX HEALTHPOLICE HEALTHTEACHERS HEALTH FUNDOTHER

PRIVATE HEALTH - Please advise which Insurance Company?

REFERRAL - How did you hear about us? REFERRAL - How did you hear about us?Word of MouthTrinity / Westcare PatientWestcare PodiatryDoctors ReferralHealth FundInternet (Google / Social Media)Driving PastOther

REFERRAL - Who do we thank for referring you? REFERRAL - Who do we thank for referring you?Current / Former patientRather Not Say

REFERRAL - If you provide us with a name and we have their details, we aim to send then a thank you.

REFERRAL - Did the doctor issue you with an EPC form? REFERRAL - Did the doctor issue you with an EPC form?YES, Please select Medicare PatientNO

PATIENT TYPE - Private / Medicare / MVA / Return to Work / DVA / NDIS PATIENT TYPE - Private / Medicare / MVA / Return to Work / DVA / NDISPrivate PatientMedicare - EPC (Enhance Primary Care)MVA - Motor Vehicle Accident ClaimReturn to Work ClaimDVA - Department of Vetrans AffairsNDIS - National Disability Insurance Scheme

EPC - REFERRAL LETTER - Do you have an EPC Referral from your GP? EPC - REFERRAL LETTER - Do you have an EPC Referral from your GP?YESNO, Without an EPC, you will be seen as a Private Patient.

MEDICARE - Name of referring GP listed on referral MEDICARE - Name of referring GP listed on referralSame as GP details aboveOther

MEDICARE - Please advise GP's name

MEDICARE - Clinic of referring GP MEDICARE - Clinic of referring GPSame as GP details aboveTrinity / Westcare Medical CentreOther

MEDICARE - Please advise name and location of clinic

MEDICARE - I understand that I require my EPC Referral & Medicare Card in order to claim my consult through Medicare MEDICARE - I understand that I require my EPC Referral & Medicare Card in order to claim my consult through MedicareYES, I understandNO

MEDICARE - I give permision for Select Health Group to communicate with my GP. MEDICARE - I give permision for Select Health Group to communicate with my GP.YESNO

MEDICARE - I understand that Medicare is not BULK BILLED, and payment is required upfront. Select Health Group can then arrange the rebate with medicare. MEDICARE - I understand that Medicare is not BULK BILLED, and payment is required upfront. Select Health Group can then arrange the rebate with medicare.YESNO

MVA - Has the accident been reported to Police? MVA - Has the accident been reported to Police?YESNO

MVA - CTP Accident Report Form completed by the driver or registered vehicle owner? MVA - CTP Accident Report Form completed by the driver or registered vehicle owner?YESNOUNSURE

MVA - CTP Injury report form completed by the injured person? MVA - CTP Injury report form completed by the injured person?YESNO, you will need to be seen as a private patient.

MVA - Have you been given a CTP claim #? MVA - Have you been given a CTP claim #?YESNO, you will bee seen as a private patient.

MVA - What is your claim #?

MVA - Who is the claims insurer ? MVA - Who is the claims insurer ?ALLIANZAAMINRMAQBEYOUIOTHER or INTERSTATEUNKNOWN

MVA - If other or Interstare please provide details ?

MVA - Do you have the contact details of your claims manager? MVA - Do you have the contact details of your claims manager?YESNO

MVA - Please provide claim managers name?

MVA - Claim Manager Phone Number

MVA - Claim Manager Email

MVA - Do you give permission for Select Health Group to communicate with your claims manager? MVA - Do you give permission for Select Health Group to communicate with your claims manager?YESNO

MVA - Have you reported your injuries to your GP for issue of a referral for treatment? MVA - Have you reported your injuries to your GP for issue of a referral for treatment?YESNO

MVA - Have you previously used a physiotherapist (or other health provider) for treatment in relation to injuries claimed as a result of this motor vehicle accident? MVA - Have you previously used a physiotherapist (or other health provider) for treatment in relation to injuries claimed as a result of this motor vehicle accident? YESNO

MVA - DATE OF ACCIDENT - (DAY) MVA - DATE OF ACCIDENT - (DAY)01020304050607080910111213141516171819202122232425262728293031

MVA - DATE OF ACCIDENT - (MONTH) MVA - DATE OF ACCIDENT - (MONTH)JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

MVA - DATE OF ACCIDENT - (YEAR - YYYY)

MVA - Suburb of Accident

MVA - Has permission for treatment for these injuries been challenged or denied by the Insurer? MVA - Has permission for treatment for these injuries been challenged or denied by the Insurer?YESNO

MVA - Have you engaged the services of a solicitor? MVA - Have you engaged the services of a solicitor?YESNO

MVA - Solicitor/Lawyer Company

MVA - Solicitor/Lawyer Phone #

MVA - Please list all injuries sustained and/or symptoms experienced since/due to the accident (Specific medical diagnosis not required)

RTW - Have you reported the injury to your employer? RTW - Have you reported the injury to your employer?YESNO, you will be seen as a private patient

RTW - Have you seen your doctor to complete Return to Work forms? RTW - Have you seen your doctor to complete Return to Work forms?YESNO

RTW - Have you received a claim number? RTW - Have you received a claim number?YESNO

RTW - Claim Number

RTW - Claims Agent RTW - Claims AgentEML - Employers MutualGB - Gallagher BassettEnABLE UnitOther

RTW - Please advise your claims managers name

RTW - Claims Manager Phone Number

RTW - Claims Manager Email

RTW - Claim Status RTW - Claim StatusAPPROVEDPENDING / IN PROGRESSCONTESTED OR DENIED

RTW - Do you give permission for Select Health Group to communicate with your claims manager? RTW - Do you give permission for Select Health Group to communicate with your claims manager?YESNO

RTW - EMPLOYER - Business Name

RTW - EMPLOYER - Business Address

RTW - EMPLOYER - Contact Person

RTW - EMPLOYER - Contact Position

RTW - EMPLOYER - Contact Phone #

RTW - EMPLOYER - Contact Email

RTW - Area Injured/Condition

RTW - DATE OF INJURY - (DAY) RTW - DATE OF INJURY - (DAY)01020304050607080910111213141516171819202122232425262728293031

RTW - DATE OF INJURY - (MONTH) RTW - DATE OF INJURY - (MONTH)JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

RTW - DATE OF INJURY - (YEAR - YYYY)

RTW - Have you engaged the services of a solicitor to assist with the claim? RTW - Have you engaged the services of a solicitor to assist with the claim?YESNO

RTW - Solicitor company name?

RTW - Solicitor Name?

RTW - Solicitor Contact Number?

RTW - Solicitor Contact Email?

DVA - CARD TYPE DVA - CARD TYPEWHITE CARDGOLD CARD

DVA - Do you have a D904 referral form from your doctor? DVA - Do you have a D904 referral form from your doctor?YES, please bring to appointmentNO, you will be seen as a private patient

DVA - DATE OF REFERRAL - (DAY) DVA - DATE OF REFERRAL - (DAY)01020304050607080910111213141516171819202122232425262728293031

DVA - DATE OF REFERRAL - (MONTH) DVA - DATE OF REFERRAL - (MONTH)JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

DVA - DATE OF REFERRAL - (YEAR - YYYY)

DVA - Name of referring GP listed on referral DVA - Name of referring GP listed on referralSame as GP details aboveOther

DVA - Please advise GP's name

DVA - Clinic of referring GP DVA - Clinic of referring GPSame as GP details aboveTrinity / Westcare Medical CentreOther

DVA - Please advise name and location of clinic

DVA - Have you seen another therapist since the referral was issued? DVA - Have you seen another therapist since the referral was issued?YESNO

DVA - I understand that I require my D904 referral & DVA Card in order to claim my consult through DVA DVA - I understand that I require my D904 referral & DVA Card in order to claim my consult through DVAYES, I understandNO

DVA - I give permision for Select Health Group to communicate with my GP. DVA - I give permision for Select Health Group to communicate with my GP.YES, I give permmisionNO

NDIS - Is your funding plan managed? NDIS - Is your funding plan managed?YESNO

NDIS - Plan Manager (Company)

NDIS - Plan Manager (Phone Number)

NDIS - Plan Manager (Email address)

NDIS - Are you self funding? NDIS - Are you self funding?YES - I will cover the cost myselfNO - Unfortunately SHG is unable to bill NDIS on your behalf.

Any further Information, you may wish to advise?

NON ATTENDANCE FEES - Late cancellation with less than 12 hours notice or non attendance maybe billed. NON ATTENDANCE FEES - Late cancellation with less than 12 hours notice or non attendance maybe billed. NON ATTENDANCE FEES - I understand and accept.

ACCOUNTS are to be finalised on the day of treatment unless prior approval has been confirmed with Select Health Group. ACCOUNTS are to be finalised on the day of treatment unless prior approval has been confirmed with Select Health Group. ACCOUNTS - I understand and accept

I have read and understood the Terms and Conditions in the attached I have read and understood the Terms and Conditions in the attached TERMS & CONDITIONS