Patient Intake

"*" indicates required fields

PATIENT INFORMATION

Title*

First Name*

Last Name*

Preferred Name*

Date of Birth*

Age*

Gender*

Address

Suburb

State

Post Code

Mobile No*

Home Phone

Email*

Occupation

EMERGENCY CONTACT

First Name

Last Name

Relationship

Phone

HOW DID YOU HEAR ABOUT US?

Other*

MEDICARE AND PRIVATE HEALTH DETAILS

Medicare No

Individual Reference Number

Expiry

Private Health Insurer

Member No

CONCESSION CARD

Pension/HCC No

Expiry

Type

DVA No

Type

HEALTH CONCERNS

Is your attendance related to any of the available insurances or groups?

Other

Name of Insurer

Claim/Policy No

Case Manager

Contact No

INSURANCE INFORMATION

Please briefly describe your primary health concerns you would like addressed.

HEALTH GOALS

What are your goals or expectations in receiving treatment with WLC Medical?

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PRIVACY AND CANCELLATION POLICIES

In order to provide you with the best care possible, we are required to collect and file personal information for future reference. We take every precaution in protecting and storing this information and only use it for professional purposes and with your consent, in accordance with the Privacy Act 1988. We keep it only as long as required by law, or as required in providing the best possible patient care. If you need to reschedule or cancel, please give a minimum 24 hours’ notice where possible. If you cannot attend, with enough notice, we can allocate your appointment to another patient. In keeping with standard practice and being respectful of our clinicians’ time and of other patients who may require a consultation, in the event less than 2 hours’ notice is given to cancel an appointment, or you fail to give notice and do not attend, you may be liable to pay the full cost of the consultation.

CONSENT

CONSENT*

I consent to the above policies and my personal information being made available to WLC Medical to help assess my health concerns, advise me of my options and to maintain contact with me.

Signature

Date