New Patient

New Patient Details

Name(Required)

Prefix First Last

If Under 18 please include full name of Guardian

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

EMAIL ADDRESS:(Required)

Phone (Home)

Phone (Work)

Phone (Mobile)

Date of Birth(Required)

Occupation

Private Medical Cover

Please complete if applicable, specify your Private Health fund

Health Fund Name

Method of Payment(Required)

Referral Details

Doctor Name

AREA OF INJURY:

Why did you choose this practice?(Required)

Referred by Doctor

Previously attended

Website

Google Search

Yellow Pages

Referred by family or friend

Sporting Club Sponsorship

Other

Emergency Contact

Please include the name and phone of one person we can contact in case of emergency.

Name(Required)

Phone(Required)

WorkCover Claims

FOR WORKCOVER/ TAC /INSURANCE CLIENTS /EARLY INTERVENTION PROGRAMME WOOLWORTHS/ALDI/

Date of Injury

Claim Number

Case Manager (If Known):

Employer

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company Contact

eg Supervisor, Health & Safety Officer:

If this information changes at any time, please let us know as soon as possible, and if we can make your visit more comfortable in any way, please feel free to talk to us.

Work Cover/TAC Terms and Conditions

Patients who believe they are eligible for funding via a third party must ensure they satisfy the following criteria before requesting bulk billing:

Their injury occurred directly in relation; to their current employment, a Victorian motor vehicle incident,
The injury has been reported to their employer and all necessary internal paperwork has been completed.
Appropriate claim forms have been submitted, and a letter of approval provided
The individual patient will always be ultimately responsible for payment of all accounts in the event that Workcover/employer/TAC does not accept financial liability for our treatment services rendered.
Currently, our practice absorbs the service fee gap for Workcover & TAC funding on the patient's behalf. However all administration fees for missed appointments, late cancellations and overdue accounts will be charged directly to the patient, not the employer or Workcover insurer or TAC as applicable (see cancellation policy page 1).
We reserve the right to discontinue providing physiotherapy treatment through Workcover/TAC funding if we feel a claimant is acting either fraudulently or demonstrating non-compliance.

Patient Consent

Agreement Date

Greensborough Physiotherapy

For New Patients